i 
 

Symbolic Access: Medical students’ awareness of institutional culture 

and its influence on learning. 

 

Dina-Ruth Lulua 

0602100T 

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, 

in partial fulfilment of the requirements for the degree of Master of Health Sciences Education. 

 

Supervisor 

 Shirra Moch  

 

 

Dar Es Salaam, 2023 

 

 



ii 
 

Declaration 
I, Dina-Ruth Lulua, declare that this research report is my own, unaided work. It is being 

submitted for the degree of Master of Health Science Education at the University of 

Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination 

at any other university. 

 

 

 

________________________________________________ 

Signature of Candidate 

 

15th day of June 2023 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iii 
 

Dedication  
To every writer, 

“Writing is hard work. A clear sentence is no accident. Very few sentences come out right the 

first time. Remember this in your moments of despair. If you find that writing is hard, it’s 

because it is hard.” 

William Zinsser 

‘On Writing Well’ pg. 9 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



iv 
 

Abstract 
Background: The discussion of access in medical education commonly has its focus on physical 

and epistemological access, leaving a qualitative gap regarding sociocultural factors which 

influence access in this context. This study introduces and defines symbolic access, a concept 

with a specific lens on sociocultural inclusion, and the impact it has on student learning within a 

South African medical school. 

 

Methods: : A phenomenographic design was used to explore conceptions of symbolic access and 

its impact on learning. Fifteen one-on-one exploratory interviews were conducted with final year 

medical students, a sample exposed to the entire 6-year medical programme. Interviews were 

analysed using Sjöström and Dahlgren‘s seven-step phenomenography model. 

 

Results: Four categories of description were induced, describing students’ understanding of 

symbolic access, these were rejection, disregard, alienation and actualization. Five dimensions of 

variation were discovered, and they expressed the different ways the conceptions were 

experienced, these dimensions were: interactions with educators, peer relationships, 

educational environment, race and hierarchy. Categories of description and dimensions of 

variation formed the Outcome Space, a visual representation of the student experience of 

symbolic access. The outcome space had a double narrative related to symbolic access; exclusion 

(major) and actualization (minor). Medical student’s chief experience within the medical 

community was exclusion, however experiences of peer-relationships, clinical skills lessons and 

participation within the clinical setting facilitated feelings of community inclusion and impacted 

learning. 

 

Conclusion: Despite exclusionary experiences, students articulated an awareness of attaining 

symbolic access during the clinical years, additionally meaningful and transformative learning 

experiences were described during these same years. The study found that attainment of 

symbolic access and students’ perceptions of valuable learning are linked. Health profession 

educationalists should design undergraduate curricula with early clinical immersion at the fore 

and explore symbolic concepts pertaining to access, as they are connected to meaningful learning 

experiences for the medical student.  

 

 

 

 

 

 

 



v 
 

Acknowledgements 
‘…It’s useless to rise early and go to bed late and work your worried fingers to the bone. Don’t you 

know He enjoys giving rest to His beloved?” Thank you, Holy Spirit. 

Smalley, my deepest love, and gratitude to you always. I am truly blessed to share everything 

with you…especially the completion of this work across 10 African countries! 

Mommy, Agasi, Mungufeni, Edoru and Daddy, thank you for the prayers and encouragement. 

Friends, words are not enough! Thank you. 

Lynne ‘Slo’ Slonimsky you brought out the problem I wanted to solve during our talk that night. 

Bless you. 

Hilary, thank you for always asking me to explain and define what was going on in my head, for 

every correction, and most especially for being you. 

Shirra, you pushed me to look for meaning in every sentence, which helped me to cross a BIG 

threshold, thank you for helping to birth this baby. 

Koki, Trev and Thakadu, my comrades, this fight would not have been the same without each of 

you. 

Dr M, thank you for always supporting me, always. 

 

Lastly to each participant from the MBBCh class of 2020, this work would not have been possible 

without your honesty, words, and experiences. Thank you for sharing them with me. 

 

 

 

 

 

 

 



vi 
 

Table of Contents 

 
Symbolic Access: Medical students’ awareness of institutional culture and its influence on learning. i 

Declaration ii 

Dedication iii 

Abstract iv 

Acknowledgements v 

Table of Contents vi 

List of Abbreviations and Acronyms viii 

List of Figures viii 

List of Tables ix 

Chapter One: Introduction 1 

Symbolic Access in Teaching and Learning 2 

Situated Learning Theory and Symbolic Access 3 

Chapter Two: Literature Review 4 

South Africa, Symbolic Access and Higher Education 5 

Rationale for Research 7 

Research Question 8 

Aim of Study 8 

Objectives of Study 8 

Chapter Three: Methodology and Methods 9 

Theoretical Framework 9 

Methodology 9 

Study Setting 10 

Study Population 11 

Study Sample Selection 11 

Sample Size and Data Saturation 11 

Convenience Sampling 12 

Realized Sample 13 

Positionality and Bracketing of the Researcher 14 

Data Collection 14 



vii 
 

Trustworthiness in Phenomenographic Research 19 

Ethical Considerations 21 

Chapter Four: Findings and Discussion 24 

Categories of Description 26 

Dimensions of Variation 29 

The Outcome Space 29 

Discussion 32 

Part I: The Outcome Space, what does the data mean? 32 

Part II: Awareness of Symbolic Access: Do you feel like you’re part of the team? 41 

Part III: How does symbolic access impact learning? 43 

Chapter Five: Conclusion 46 

Study Limitations 46 

Recommendations 47 

Reference List 49 

Annexure A 60 

Annexure B 62 

Annexure C 63 

Annexure D 64 

Annexure E 65 

Annexure F 67 

Annexure G 68 

Annexure H 69 

Annexure I 69 

                                                                                                                                                                                                                   

 

 

 

 

 



viii 
 

List of Abbreviations and Acronyms 
CoD                               Categories of Description 

CoP                                Community of      Practice 

DoV                                Dimensions of Variation 

GEMP                             Graduate Entry Medical Programme 

HREC                              Human Research Ethics Committee 

LPP                                 Legitimate Peripheral Participant 

MBBCh                          Bachelor of Medicine and Bachelor of Surgery 

MS                                  Microsoft 

SC                                    Socioconstructivism 

SoC                                 Students of Colour 

Wits                               University of the Witwatersrand 

 

 

 

 

 

 

 

 

 

 



ix 
 

List of Figures 

Figure 1.1: Physical and Epistemological Access 

Figure 1.2: Symbolic Access 

Figure 2.1: Final Year Medical Students Year End Photo 2017 

Figure 3.1: Categories of description and Dimensions of variation in relation to phenomenon 

Figure 4.1 Chronological Outcome Space 

Figure 4.2: Progression of legitimate peripheral participant in community of practice 

Figure 4.3: Students Perceptions of learning with and without awareness of Symbolic Access 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



x 
 

List of Tables 

Table 3.1: Study Population and Realized Sample Demographics 

Table 4.1: Tabular Outcome Space



 

  
 1 
 

Chapter One: Introduction 
Over the past fifty years there has been a global widening of access in higher education.1 This 

expansion included policy creation to close access gaps, targeted funding of certain population 

groups, increases in accredited distance learning programmes and plans to establish an 

estimated 150 million universities worldwide by the year 2025.1,2 These initiatives focused 

primarily on physical access to higher education with limited attention to access through the 

symbolic lens. The symbolic lens constitutes an institution’s culture, traditions and implicit codes 

which shape it as a community.3 This symbolic space is bound by intangible yet present borders 

that define some people and groups as included while excluding others.4 The discussion of access 

in higher education, therefore, goes beyond formal admission into physical spaces or the 

availability of knowledge, to include the symbolic entry into a group or community. 

 

In literature the term access  has been theorised as ‘all possible means by which a person or 

persons is able to benefit from certain things’.5  This study conceptualises a definition of access 

from the Ribot et al5 and Binderkrantz et al6 , and proposes the definition to be; when an 

outsider/s cross a threshold controlled by relevant gatekeepers, and through this crossing the 

outsider/s benefits from things within the community—including material objects, knowledge, 

persons and institutions.5,6 In teaching and learning Cele and Brandt8 categorise access into two 

parts, namely physical, and epistemological access. Physical access is access to the space and 

resources that higher education institutions provide, it aims to ensure all those entering higher 

education are qualified to enter. Epistemological access refers to access to academic literacies 

(curriculum content and knowledge) which are needed to succeed in higher education (Figure 

1.1).8 



 

  
 2 
 

 

Figure 1.1: Physical and Epistemological Access 

These educational categories, however, do not account for access to the symbolic aspects of 

teaching and learning, leaving a notable gap for the introduction of symbolic access in teaching 

and learning.  

 

Symbolic Access in Teaching and Learning 

Distinctions between people, groups and things create the boundaries that separate us physically 

and symbolically. Symbolic boundaries house an institution’s culture and like physical 

boundaries, symbolic boundaries require access to obtain said culture, which includes the 

institution’s traditions, behaviours, discourses and values.4,9-11 Symbolic access is an emerging 

concept; hence its definition is developing, currently its definition is conceptualised from multiple 

sources, for the purpose of this report, symbolic access will be defined as, when an outsider/s, 

are given opportunity to gain community culture and identity by gatekeepers within the 

community (Figure 1.2).4,5,9 In teaching and learning gaining symbolic access is an intangible 

event, however it can be recognised by the way the individual who has obtained it changes their 

expression both within and outside the community. In higher education, symbolic access can be 



 

  
 3 
 

facilitated through relationship development and socialisation of ‘outsiders’ (students) by 

established community members, into the cultural systems of the institution.12,13   

 

  

Figure 1.2 Symbolic Access 

 

The medical education community has a deep-rooted culture and students admitted into 

medicine come eager to learn what is necessary to be part of the community, fostering hopes of 

developing their identity as a junior doctor. Over the years the medical education community has 

been encouraged to not only supply students with programme admission and course-based 

content; but to be cognisant of the role relationship development and community socialisation 

play for the medical student.14 Through these two social events established community members 

enable symbolic access for these students. 

 

Situated Learning Theory and Symbolic Access 

Educationalists Lave and Wenger12 theorize that academic relationships and socialisation are 

integral for student learning. In their theory of Situated Learning, they assert that learning is a 

social process, shaped by the development of relationships and socialisation between 



 

  
 4 
 

newcomers (students) and old timers (educators/established community members) in a 

Community of Practice (CoP). They conclude that learning has occurred when a newcomer 

changes their participation within the community.12,13 Both symbolic access and learning require 

relationship development and socialisation to be realised. The exploration of symbolic access in 

higher education, therefore, is also an exploration of factors that influence student learning in 

higher education. 

Chapter Two: Literature Review 

Considerable educational research is driven by the question: “What factors influence student 

learning in higher education?”15-18 Commonly documented influences include student learning 

styles, teaching strategies, demographic background and the learning environment.19-23 While 

these factors have been explored extensively there is need to focus more deeply on sociocultural 

factors as they relate to student learning.24 

 

Sociocultural factors include the relationships, culture, traditions and values of a community; 

Bowles et al25 explain that in higher education these factors fall under the umbrella of 

institutional culture. How students gain access to institutional culture or their awareness of it has 

not been described or fully investigated in the literature within the South African context. 

Leibowitz et al26 explain that in order for learning to successfully occur continual consideration 

and reflection, by educators, needs to be placed on the social, cultural, and community factors 

that promote or constrain learning. An inquiry into how students recognize, and access 

institutional culture is warranted. 

 

Raso et al27 inform us that educator-student socialization, relationship development and student 

enculturation occurs in the hidden curriculum. The study of symbolic access, therefore, is situated 

in the hidden curriculum. The hidden curriculum has emerged as an influential concept in medical 

education, as researchers realized the impact this informal teaching and learning has on the 

student learning experience. Through this socially ‘taught’ covert curriculum, community values, 

norms, and attitudes are largely learnt, and these unintended socio-relational lessons may 



 

  
 5 
 

facilitate symbolic access for the student.28-32 Over the last two decades medical education has 

produced growing literature on the hidden curriculum, however Bandini et al31 highlight that 

there has been a lack of specificity in this research. Lawrence et al33 inform us that there are 

multiple ways the hidden curriculum presents itself, and that it is not just a blanketed singular 

curriculum. Researchers are encouraged to make explicit the details and nuances of the hidden 

curriculum, as being detailed will allow policymakers and curriculum developers to better identify 

literature related to their own needs and initiatives. Two thirds of current literature on the hidden 

curriculum is limited to North America, as a result the production of more contextualised studies 

from areas such as Africa has been strongly encouraged to adequately represent hidden curricula      

in their medical school contexts.33 Exploring symbolic access in medical education brings to the 

fore a nuance of the hidden curriculum and studying this nuance within a South African context 

lends itself to filing literature gaps. 

 

South Africa, Symbolic Access, and Higher Education 

The South African higher education setting is uniquely framed for the exploration of symbolic 

access. South Africa has a devastating socio-political history, which created a distinctly separatist 

higher education setting and culture. Under the Apartheid regime, South Africa had five separate 

legislative and geographic regions resulting in the establishment of 36 higher education 

institutions controlled by eight different government departments.34,35 A distinguishing feature 

of the Apartheid higher education system was the unequal access to academic, structural, 

cultural and social resources in the education of different racial groups.36 As a result of these 

disparities one of the main priorities of the post-1994 democratically elected government was to 

redress the inequalities within the higher education sector, by adopting policies that would widen 

access to higher education for all South Africans.37 This resolve was captured in the White Paper 

on Higher Education 1997, that promised a “transformed, democratic, non-racial and non-sexist 

system of higher education which promoted equity of access and fair chances of success for those 

seeking to realise their potential through higher education.”36 

 



 

  
 6 
 

Significant achievements regarding this access policy were realized, including an increase in the 

proportion of black and female students in public higher education, changes in the academic 

profiles of institutions, and the establishment of a national funding framework. However, the 

higher education mandate of the new 1994 government focused primarily on physical and 

epistemological access in higher education, neglecting to envision steps which would create 

opportunity for symbolic access in tertiary institutions.36-38 Reddy39 explains that transformation 

in South African higher education focused on issues of student intake and throughput, as well as 

the over-representation of white faculty at the expense of issues such as institutional culture and 

the implications thereof. The journey of how students would adopt institutional culture and the 

process were not deeply considered. The movement in South Africa towards granting entry into 

higher education did not necessarily equate to student [learning] success, as this physical 

provision of access did not address inclusion beyond university admission.40,41 

Some twenty years into democracy, the South African government was directly confronted with 

this symbolic oversight in what Jansen et42 describe as, “…the most intense and violent student 

protests in a century of higher education”, the #RhodesMustFall and #FeesMustFall movements. 

Two factors attributed to the 2015-2016 country-wide student protests: the alienating cultures 

of historically white universities, labelled #RhodesMustFall and the discriminatory cost of higher 

education known as #FeesMustFall movement. The #RhodesMustFall movement specifically 

brought to light the ills of cultural exclusion experienced post 1994 by the black scholar and black 

academic.43  

This narrative of cultural exclusion presented itself at University of the Witwatersrand (Wits) in 

2017, when final year medical students displayed a banner during their class photo stating ‘Wits 

Med School is Racist’ (Figure 2.1). This declaration was vehemently rejected and denied by the 

medical community in the university.44 A more insightful response, according to Mahood45 would 

have been for the academics in the programme to address the students’ perceptions of exclusion, 

and further to investigate what aspects of the curriculum, programme and institution created 

these feelings and perceptions.45 



 

  
 7 
 

 

Figure 2.1: Final Year Medical Students Class Photo 2017 44 

 

Symbolic access to institutional culture appears to be a potent stumbling block in the South 

African higher education space and more specifically in medical education. If left unexplored, 

students will continue to struggle navigating the academic space; and will be forced to exist on 

the periphery of the medical community. It is increasingly important for educators in higher 

education to shape a more inclusive  institutional culture . This would empower educators to 

thoughtfully engage students and take responsibility for the role they play in symbolic access to       

learning.46  

Rationale for Research 

Wits medical students are exposed to an established institutional culture during a six year long 

medical programme. In 2017 these students publicly expressed their experience of alienation and 

discrimination in relation to institutional culture. The Wits medical students’ experience of access 

to institutional culture and the impact it has on learning has not been formally researched or 

reported. Literature asserts that for successful learning to occur educators and education bodies 

need to continually consider and reflect on social, cultural, and community factors that promote 

or constrain learning. An inquiry into how Wits medical students recognize, and access 

institutional culture and its impact on learning is warranted in this context.  



 

  
 8 
 

 

Research Question 

How does symbolic access to institutional culture affect learning for the medical student? 

 

Aim of Study 

To explore final year medical students’ awareness of symbolic access in Wits medical school and 
the impact it has on their learning. 
 

Objectives of Study 

● Explore final year medical students’ awareness of symbolic access. 
● Explore final year medical students’ perceptions of the influence symbolic access has on 

their learning. 

 

 

 

 

 

 

 

 

 

 

 



 

  
 9 
 

Chapter Three: Methodology and Methods 
This chapter describes how the researcher systematically planned and conducted the study from 

philosophical thinking and research design to data gathering and analysis, ensuring 

trustworthiness and ethical considerations of the research. The methodology and methods 

chapter will help to ensure valid and reliable results, that address the study aims and 

objectives.47-50. 

 

Theoretical Framework 

This study was rooted in an interpretivist paradigm. Research with this world view seeks to 

interpret phenomena according to the subjective frame of those who are in the world.51 Further 

the study drew on Socioconstructivism (SC) as a theoretical framework. SC falls within the 

interpretivist spectrum and is a combination of Social Learning and Constructivist theories.52,53 

SC Theory proposes the collaboration of Social Learning Theory with works by Vygotsky, Bandura, 

and Akers and Constructivist Learning Theory as stated by Bruner. Socioconstructivism asserts 

that knowledge construction (learning) is based on an individuals’ previous knowledge and 

experiences, coupled with their interaction with the context and culture of the environment.54-56 

This framework supported the study and its methods to discover how individuals understood and 

experienced symbolic access and further how they made sense of these experiences in relation 

to their learning. 

 

Methodology 

When choosing a methodology, the most important question a researcher needs to ask is: what 

type of knowledge is required to best answer the research question? 55 The research question of 

this report sought to acquire experiential knowledge of a phenomenon, within an educational 

context, therefore phenomenography was the methodology chosen. Phenomenography is a 

commonly used qualitative methodology within the social and health sciences. It was developed 

in response to educational research needs at Göteborgs University in Sweden.57 As a research 

design, phenomenography aims to answer specific questions about thinking and learning, and it 

helps to describe the variation of ways that people experience the same phenomenon.  In medical 



 

  
 10 
 

education, phenomenography is used to encourage the use of varied teaching and learning 

interventions according to the unique experiences of the participants. Further it has allowed an 

understanding of varied student learning experiences within the discipline.58-61  

 

Study Setting 

The study setting is the physical or social environment in which the research is conducted based 

on the study aims. For this study, the researcher aimed to investigate symbolic access in medical 

education and establish its influence on learning, therefore a unit for undergraduate medical 

education at a research-intensive university in Johannesburg, South Africa was chosen. When 

selecting a study setting it is important that it provides the researcher access to study participants 

who can give insight and relevant information on the topic being studied.62,63 The selected unit 

coordinates the undergraduate medical degree in the School of Clinical Medicine in the Faculty 

of Health Sciences in the university, which provided appropriate access to study participants. 

In qualitative research, it is important for the researcher to elaborate on the social context of the 

study setting as it adds historical and current insight to the investigation.63 The medical school, 

where this study was conducted, is a historically White Anglo-Saxon influenced university, 

founded in 1916 by a homogenous all male, all White committee.64 South African medical 

institutions are deeply rooted in cultures of educational exclusion based on race, gender, religion 

and class. This segregation translated to how students were taught (and by who), the hospitals 

they could attend, patients they had access to as well as social interactions within the 

institution.65 Over the years there has been significant diversification of the institution and 

medical school community; the institution now consists of a community which is much more 

representative of the South African population at large. 

At this university, the medical degree (MBBCh) is 6 years long. There are two entry points into 

the degree: as a secondary school leaver into the first year of the programme or as a graduate 

into the third year as part of a Graduate Entry Medical Programme (GEMP). The Faculty of Health 

Sciences is adjacent to a quaternary level teaching hospital, and five kilometres from the site of 

the central University administration and most other teaching facilities. Students who join the 



 

  
 11 
 

degree programme from high school spend the first year on this university site, remote from the 

health sciences campus. From second year onwards, these same students move to the health 

science campus. First to fourth year students spend ninety percent of their almanac in didactic 

teaching, while fifth- and sixth-year students spend ninety five percent of their academic calendar 

in the clinical setting as they rotate between three academic hospitals for teaching in 

Johannesburg and Soweto.  

Study Population 

A study population is defined as the targeted study group of interest to the researcher, who meet 

the study criteria, which serves as the larger group from which a study sample is selected.50 The 

study population of this project was the 2020 final year medical students’ (n=321) outlined in 

Table 3.1.  

 

Study Sample Selection 

Participant selection for phenomenographic studies requires the researchers to make strategic 

efforts to maximise diversity of participants selected, this ensures inclusive representation of 

participant experiences. Purposeful sampling is typically used as a selection method in 

phenomenographic studies, and when appropriately done, the selected sample allows 

researchers to learn about the entire study population.66,67 To adequately explore medical 

students’ awareness of symbolic access and its impact on their learning in this population, the 

researcher had to select participants who represented the diversity of the medical student 

demographic in this population. Participants were to be chosen based on the following pre-

selection criteria, including race, gender, age, local vs international students, graduates and 

school leavers, top, middle and lower academically scoring students. These criteria would       

enhance      representation of the study population being studied.  

 

Sample Size and Data Saturation 

In qualitative research sample sizes are usually small, with an intention of obtaining a rich in-

depth description of the phenomenon of interest. The sample size of this study was 15 

participants, phenomenographic studies typically suggest a sample of 10-15 participants as 



 

  
 12 
 

sufficient to capture variation and reach saturation, at which point no new information emerges 

from the data. There is no recommended upper limit currently, however sampling should ensure 

that the resulting amount of data remains manageable.66,68 

 

In qualitative research there are several debates concerning sample size in relation to data 

saturation. Data saturation is an important concept in qualitative circles as its deemed the 

compass that guides the researcher about the ‘right’ sample size for their project.69,70 Although 

commonly used data saturation is frequently contested, multiple researchers argue that 

saturation is a poorly defined concept; often expressing there is no agreed method of establishing 

saturation.71 Over the years the idea of sampling until data saturation is reached has been raised 

in several health-related disciplines. In health professions education, qualitative research 

scholars add to the debate by stating that, there is no consistent explanation as to how saturation 

has been achieved amidst the claim that saturation is reached.71 In light of these differences, up 

until today, researchers seek to truly define saturation; in order to give a clear outline of when 

saturation is reached and provide some guidance regarding how many interviews, or focus 

groups are sufficient to validate the sample size.71,72 

 

 The chosen sample size for this project falls within the recommendation for qualitative and 

phenomenographic studies. The size also aligns to current medical education debates, which 

recognizes that saturation and sample size is still an ongoing discussion within qualitative 

research. Further the decision to stop interviewing after 15 interviews was based on logistics, 

advice from the supervisor, informed by literature, and the limitations of a research report 

dictated the end point. 

  

Convenience Sampling 

This study was conducted in 2020, and due to the COVID-19 pandemic, academic disruption and 

the abrupt university closure coupled with a short time frame to invite and interview participants 

before graduation, convenience sampling, instead of purposeful sampling, was conducted. 

Convenience sampling is the most common qualitative sampling method used.67 Participants are 



 

  
 13 
 

selected based on their availability in location, time, access, and willingness. It is a fast and a 

more convenient way to achieve the sample size required for a study. Following an invitation 

email sent to the entire class, nineteen final year students showed interest in being participants, 

the first 15 participants who were readily available were interviewed and became the realised 

sample. 

 

Realised Sample 

The realised sample, depicted in Table 3.1, had an acceptable degree of diversity with regards to 

participants’ race, age, academic performance, gender, entry point into medicine and country of 

origin. This diversity was sufficient in order to provide insight into the study population. 

 

 

Table 3.1: Study Population and Realised Sample Demographics 

 



 

  
 14 
 

Positionality and Bracketing of the Researcher 

As the primary researcher I recognize and acknowledge my fixed and subjective positionality that 

may influence this research study.73 I am a 35-year-old, African, female of Ugandan-South African 

heritage. I am a graduate of the MBBCh programme under investigation (2011) and have lived 

through the process of being a medical student within the institution. I have my own 6-year lived 

experience of institutional culture within the medical school as a young Black female student. As 

a medical officer, I was recruited into the medical education space to teach in this institution 

because of my race, gender, alumni status and millennial relatability. I taught clinical skills to the 

study participants during their 3rd and 4th medical years (2017 and 2018) and over the two years 

have developed rapport with the students and class as a whole. Until recently I coordinated the 

third and fourth medical years at the medical school, and therefore have a past and present 

insider stance. I draw on racial, social, educational, symbolic, theological, scientific and creativity 

theories to make sense of the world and am constantly conscious of my race, gender, and faith 

as I navigate every day.  

 

I recognize that each aspect described influenced this research process i.e., my identity, lived 

experience of the university as a student and educator, engagement with the participants, 

theoretical beliefs, and perspective through which I viewed the research process as a novice 

researcher.73,74 Deeper, I acknowledge that my positionality shapes my work and influences my 

interpretation, understanding, and belief in the truthfulness and validity of the participant 

experiences.  

 

Data Collection 

In qualitative study designs, value is placed on the depth of data collected, as opposed to the 

breadth; through various approaches such as in-depth interviews, focus groups or participant 

observations, the researcher can collect large amounts of data from a small sample.75 In this study 

the researcher conducted individual in-depth interviews as per phenomenographic 

recommendation.76,77 In-depth interviews are a conversational approach which seek detailed 

information from a small number of participants, over a significant amount of time. This format 



 

  
 15 
 

helped to shed light on participants’ thoughts, experiences, feelings and understanding of 

symbolic access. Facilitating the researcher to collect information regarding the phenomenon 

and to address the research question.78 

 

Method of Data Analysis 

The main aim of phenomenographic data analysis is to produce an outcome space, this space 

presents the qualitatively different ways participants understood the phenomenon and shows 

which experiences facilitated these understandings.76 The first steps of phenomenographic 

analysis are similar to those of a thematic inductive analysis, the raw data are analysed, using a 

constant comparative method, and codes or variations are determined. After initial coding, a 

comparison of codes’ similarities and differences is done, and the end result is the emergence of 

specific Categories of Descriptions (CoD) and Dimensions of Variation (DoV).79,80 The CoD’s 

demonstrate different ways the phenomenon is understood and the (DoV) show how the 

categories of descriptions are experienced and relate to each other (Figure 3.1) In 

phenomenography emphasis is placed on searching for the collective meaning rather than 

describing each individual’s experience, hence CoD’s are created.76 Lastly all categories and 

variations are integrated into the outcome space.80 

 

Figure 3.1: Relationship between Categories of description and Dimensions of variation. 



 

  
 16 
 

Data Collection: Tool 

In qualitative studies the main data collection tool is the researcher, and the questions they 

formulate.81 For this study, the researcher created two open-ended questions with the guidance 

of her supervisors and a postgraduate assessor panel (Annexure H). Open-ended questions were 

created as they helped the researcher learn more about the topic, without attributing any bias 

or preconceived notions, leading to a discovery-oriented research approach.81 Qualitative 

research questions are often semi-structured or open-ended and thus can be ‘unique’ to the 

study.83  

 

Two prompt questions were also included, again with the guidance of supervisors. These prompt 

questions helped to solicit further detail and depth from participants; allowing the researcher to 

peel back information one layer at a time.824All questions were assessed and revised prior to data 

collection, and when designing the questions, the researcher referred to the research question, 

aims and objectives to make sure the questions would satisfy the study.  

 

Data Collection: Process 

Pre-Interview 

After receiving ethical clearance, the researcher sent an email to the administrator of the 6th year 

medical programme, requesting an invitation email be sent to the entire 2020 final year student 

body inviting them to participate in the study. This email was sent directly to individual student’s 

email accounts and contained an introductory letter explaining the research, the ethical 

clearance certificate, and the participant information sheet. Potential participants were invited 

to contact the researcher via email or the Telegram application if they required more information 

about the research and/or were interested in being interviewed. Of the students who contacted 

the researcher, 16 were via email and 3 via Telegram. Once the researcher answered all student 

questions and confirmed a student wished to participate, the researcher sent each participant 

two consent forms: informed consent and digital audio recording consent form and requested 

the student sign each and return these to the researcher before the interview date and time were 



 

  
 17 
 

confirmed. For convenience, the first 15 participants to respond became the realised study 

sample. 

 

When all completed consent documentation was received and filed in a secure electronic folder, 

two possible interview dates and times were suggested to each participant, with the additional 

option for the participant to inform the researcher should none of the proposed interview dates 

be convenient to them; this was in order for them to come to an agreement regarding the best 

interview date and time for the participant.  

At the start of the research process, it was anticipated that interviews would be conducted face 

to face, however due to strict COVID-19 lockdown regulations all interviews needed to be 

conducted remotely. Every participant was informed of the proposed duration of the interview 

(60 minutes) and asked if an online or telephonic interview was suitable; being mindful of time, 

data considerations, and device access. All 15 participants requested to be interviewed online via 

the Microsoft (MS) Teams application, as all university students had access to this online 

application. The researcher set up online meetings and sent the meeting link to every participant 

via their student email. Each participant was given a pseudonym, which was the title of their 

online interview link. With the link provided, participants were able to join the session via their 

laptop, tablet, or cell phone. Participants were given the option to switch their camera on or not, 

depending on internet bandwidth and comfortability. Online interviews were conducted from 

29th April to 08th September 2020. 

The researcher practiced her interview skill prior to this project, she conducted three interviews 

of senior colleagues within the university, which were audio recorded for a master’s degree 

assignment. It is important for the novice interviewer to practise their interview technique 

repeatedly under supervision in order to become more comfortable and to become attuned to 

themes which may emerge during the process.78 As a novice interviewer the researcher sought 

guidance from her supervisors and shared early interview recordings with them for feedback 

regarding interview technique.  

 



 

  
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The Interviews 

At the start of each interview the researcher introduced herself, briefly explained the interview 

process and what would occur. Participants were given the opportunity to ask additional 

questions before the start of the interview and due to the sensitivity of the topic were again 

informed that anonymity would be maintained. Additionally, participants were told that they had 

the right to omit answering certain questions and could withdraw from the interview at any time 

without consequence, should they feel uncomfortable or unable to continue. Participants were 

informed when the interview recording started and that a copy of the interview recording would 

be available to them on request. The researcher started each interview with the following 

‘icebreaker’ question “Why did you choose to study medicine?”. This question aimed to get the 

conversation started and establish basic rapport, after this question the researcher asked the 

study questions. During the conversation, the researcher took notes as participants spoke and 

asked questions based on what was expressed by the participants, the researcher also continually 

encouraged participants to elaborate or expand on meanings and thoughts expressed.  

 

During and after each interview the researcher took notes of how best to conduct future 

interviews; from the introduction to the way questions were asked; utilising these noted 

techniques in subsequent interviews. After each interview, the researcher started to learn better 

interview techniques i.e., to listen instead of lead, discover rather than direct, and during 

discussions with her supervisor, determined better ways to conduct subsequent interviews. 

 

Post-Interview 

Every interview was recorded via MS Teams by the researcher, interviews were then downloaded 

and saved in a password protected electronic file on the researcher’s laptop. The researcher 

shared the interview recordings with her supervisors by creating a password protected MS 

Streams group, which allowed them to listen to the interview recordings. Phenomenographic 

interviews are typically recorded and transcribed verbatim for subsequent analysis. All 15 

interviews were transcribed verbatim from audio recordings, and all transcriptions were saved in 

a password protected electronic Word file. Participants were given the opportunity to review the 



 

  
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final recording and transcript as a true reflection of the interview. No participant requested a 

review. Transcripts were reviewed while listening to interview audio recordings, this helped the 

researcher get a general overview of the interviews and functioned as the start of the data 

analysis process. 

 

Trustworthiness in Phenomenographic Research 

In the research process, it is important to establish the credibility of findings presented. It is 

suggested that researchers answer the following questions to determine research rigour; 1.How 

did the researcher establish that findings presented are genuine?, 2.How can we determine the 

applicability of the findings in other settings/with other responders?, 3.How can we know if the 

same findings would be repeated with similar participants in the same context?, and 4.How can 

we determine if the findings come solely from participants and are not influenced by the 

researchers?83  Qualitative research approaches are diverse, consisting of a variety of 

philosophical paradigms and therefore requiring different criteria for answering the four 

questions mentioned .Golafshani83 informs us that Lincoln and Guba propose that for qualitative 

research trustworthiness can be established by the following four criteria Credibility (internal 

validity), Transferability (external validity), Dependability (reliability) and Confirmability 

(objectivity).85 These four criteria were used for this phenomenographic study. 

 

Credibility 

Credibility is the confidence that can be placed in the truth of the research findings, confirming 

whether or not the research findings represent acceptable information drawn from the 

participants’ original data and is a correct interpretation of their original views.85 In this project 

strategies used by the researcher to establish credibility included practising her interview 

technique with supervisor checks, clarifying researcher bias by declaring and accepting her 

positionality relating to the study context and keeping a field journal to demonstrate her 

conceptual lens and introspection during the research process. The journal helped the researcher 

to reflect on comments and experiences mentioned by the participants, introspect on her own 

experience of the same context and understand her connection and need for intentional 



 

  
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separation from the study participants. Taking personal notes assisted with future interviews and 

validated her own lived experience. 

 

Transferability  

Transferability refers to the degree to which the results of qualitative research can be transferred 

to other contexts with other respondents i.e., generalizability for the interpretivist.85,86 

Transferability has been enhanced by providing a clear context of the country, its socio-political 

and higher education history, clear context of the medical school, its medical programme and in-

depth class demographic of those who were invited to participate as well as the realized study 

sample. These detailed descriptions will help other researchers to make a judgement about the 

findings fitting in with their contexts and further to replicate the study with similar conditions in 

their settings. 

 

Dependability  

Dependability is important as it determines whether the findings of a study can be consistently 

repeated if the inquiry is to be replicated with the same or similar respondents in the same or 

similar context. Dependability is established by clear stepwise documentation of the research 

process, auditing, coding, and re-coding during the research process.85,86 This research study  

describes in detail coverage of the methodology and methods used, allowing the reader to assess 

the extent to which appropriate research practices have been used and followed. This detail 

included outlines of the study design, its appropriateness and implementation, in-depth details 

of data collection and methods utilised, along with clear field and journal notes. 

 

Confirmability  

Confirmability is the degree to which the results of a study can be confirmed by other 

researchers, which helps to establish that the data and interpretations of the findings are solely 

from participants and not based on the primary researchers’ biases, interests, and 

perspectives.83,84 During this study there were consistent weekly consultations with the study 

supervisors to discuss findings, develop phenomenographic categories and variations. 



 

  
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Ethical Considerations 

The protection of research participants through the application of appropriate ethical principles 

is important in research.85 The responsibility of ensuring that this research project was conducted 

ethically lay with the researcher, who under the guidance of supervisors, made sure that all 

phases of the study were carried out in an ethical manner, especially abiding to ethical principles 

when choosing potential research participants. Arifin87 suggests five ethical issues that must be 

considered in research namely, Informed Consent and Voluntary Participation, Anonymity and 

Confidentiality, the Interview session, Data Analysis and Dissemination of Findings and Data 

Protection.87 The first step being establishing ethical approval to conduct the study, the following 

permissions were obtained to conduct this research. 

 

Ethical Permission Requested and Obtained: 

Permissions to conduct the study were requested and obtained from:  

● The Postgraduate Assessors Committee Researcher Assessors Panel 30th September 2019. 

(Annexure A) 

● Head of School of Clinical Medicine, Prof Daynia Ballot, as the study cohort (final year 

medical students) belong to the School of Clinical Medicine in the Faculty of Health 

Sciences, 1st October 2019. This allowed the researcher to obtain demographic data of 

the study cohort. (Annexure B) 

● The University of the Witwatersrand Human Research Ethics Committee (HREC) Medical 

on 12 March 2020. Unconditional Approval. (Annexure C) 

● The University of the Witwatersrand Deputy Registrar, Mrs. Nicoleen Potgieter on 11th 

February 2020. This allowed the researcher to conduct research on university premises, 

and/or involving staff and/or students at the University as research participants. 

(Annexure D) 



 

  
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Informed Consent and Voluntary Participation 

In ethically considered research, consent is voluntary (freely given). Participants understand what 

is being asked of them and must be competent to give consent. It is important that participants 

are fully informed about the study and have the power of freedom of choice to allow them to 

decide whether to participate or not.87 All potential participants were sent an email informing 

them of the purpose of the study with the contact details of the researcher (email and Telegram) 

should they choose to participate. The email contained the participant information sheet with 

full details about the research study. When contacted the researcher gave time for potential 

participants to ask questions so she could address any concerns. After which she electronically 

provided every potential participant with two consent forms to complete: written informed 

consent and digital recording consent forms. The researcher requested that the participant read 

the forms, then sign them, and send back both forms, indicating their permission to be part of 

the study, before she suggested potential interview dates. This turnaround time was typically 

four days.  

 

Anonymity and Confidentiality 

Anonymity and confidentiality of the participants was established by giving each participant 

pseudonyms in place of their own names, and by not revealing their names or any form of 

identifier in the data collection, analysis, and reporting of the study findings. Privacy and 

confidentiality of the interview environment were managed during and after the online interview 

session, data analysis and dissemination of the findings. Further, in the participant information 

sheet, participants were requested not to discuss the interview with peers. 

 

Interviews and Beneficence 

During the interview process, it was important to ensure the well-being of the participant, who 

also had a right to protection from discomfort and harm elicited by the interview session. Each 

interview was set up via a private meeting link by the researcher, emailed directly to the 

participant, which they could use to join the one-on-one interview meeting. The researcher is the 



 

  
 23 
 

only one who can match the identity of the participants and voice recordings. It was explained 

that as their participation was voluntary, withdrawing from the study at any point would not 

affect their academic marks, clinical rotations, or any aspect of their degree. Additionally, they 

could choose not to answer questions should the question cause discomfort. Due to the 

sensitivity of the study, contact details for counselling services were made available to 

participants. Counsellors are available free of charge via the Faculty Office of Student Success. 

Participants were also encouraged to ask the researcher any questions during or after, about the 

research. If participants had any concerns or complaints regarding the ethical procedures of the 

study, they were provided the details of the Chairperson and Senior Administrator of the HREC 

(Medical) Committee to contact. 

 

Data Analysis and Dissemination of Findings 

Identities of the participants were removed during data transcription, including their names 

and/or any significant identifiers. Participants were always referred to by their pseudonym 

names in the transcript or verbatim quotes. All consent forms or any document which contains 

the participants' personal detail was kept in a password protected electronic file solely accessible 

by the researcher. Participants were however, notified that their demographic data would be 

used for the purpose of reporting the data from the interview. Data was shared with two 

qualitative researchers, the researchers’ supervisors, for the purpose of reaching agreement of 

the interpretation without exposing the participants’ details at any stage. The access of the 

supervisors to the data was explained to participants and consent regarding this matter was 

obtained. 

 

Data Protection 

Some data analysis was conducted simultaneously with the data collection and transcription 

process. The data was privately shared with two qualitative researchers via a secured Microsoft 

Streams group. Data was stored in an electronic folder which is password protected, with the 

password only known by the researcher. Hard copies or written materials of the data were kept 

in a secured cabinet in a locked room with no access to others to ensure adherence to legal 



 

  
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requirements and ethical guidelines. Written and electronic data from this study will be stored 

for five years. However, the interview recordings will be disposed once they are no longer 

needed. The researcher was aware that any unexpected adverse event which was caused by this 

study should be reported to the HREC (Medical), however, no such event occurred throughout 

the study period. The results of the study will be reported and disseminated through a research 

report, peer reviewed scientific journals, conference presentations, and the online university 

library. All anonymised data will be securely stored for a period of ten years in accordance with 

the University of the Witwatersrand guidelines. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 

  
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Chapter Four: Findings and Discussion  

Various phenomenographic analytical methods exist, the method of analysis used in this report 

is outlined in the methodology chapter. The specific analysis steps used by this study was 

Sjöström and Dahlgren‘s seven-step process for phenomenographic data analysis88 for two 

reasons: first, these seven steps are easy to understand for the novice researcher and second, 

the steps do not conflict with the other available processes.88-90 The steps are as follows: 1. 

Familiarization, 2. Condensation, 3. Comparison, 4. Grouping, 5. Articulating, 6. Labelling, and 7. 

Contrasting.88 

 

Step 1 Familiarization: The researcher printed and read all transcripts repeatedly while 

simultaneously listening to the audio recordings, in order to familiarize herself with the data. 

Notes and sections of each interview were manually highlighted. The researcher immersed 

herself in the data to ensure in-depth understanding of the text and to get accuracy of context. 

Step 2 Condensation: Relevant recurring feelings, words, and experiences participants used were 

identified, grouped together and recorded as patterns. This was done in order to uncover 

repeated patterns or similarities in the data. 

Step 3 Comparison: The researcher studied and discussed patterns with supervisor in order to 

identify similarities and differences in the patterns. 

Step 4 Grouping: Patterns were sorted into initial Categories of Description according to the 

similarities of their essence and how the categories described the participant’s experience of the 

phenomenon - symbolic access. 

Step 5 Articulating: Categories were read and discussed between researcher and supervisor      to 

identify the essence of each category. The main aim of this step is to set up boundaries      

between the categories. 

Step 6 Labelling: After confirming the categories, the next step was to distinguish features 

between them, these become the Dimensions of Variation, and label them accordingly. 



 

  
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Step 7 Contrasting: Discussion and reviewing of categories of descriptions were held between 

the researcher and supervisor. Categories were contrasted and thoroughly defined in order to be 

clearly distinguished and arrive at the four categories in this study.  

The process of articulation, labelling and contrasting (step 5-7) was iterative, which is true to the 

nature of phenomenographic data analysis. The end goal was to define categories which best 

represented the qualitative variations of the phenomenon from the participants’ responses. 

Findings/Results 

Phenomenographic analysis results can be presented in three steps, first an introduction to the 

CoD’s, followed by an introduction to the DoV’s, and lastly the presentation of the Outcome 

Space, which is a visual representation of the intersection between the CoD’s and DoV’s.  

 

Categories of Description 

Four Categories of Description were identified during the seven-step process of data analysis. 

These expressed the collectives’ experience of symbolic access.91 Each CoD demonstrated 

different ways the phenomenon was understood or experienced by the participants. The four 

Categories of Description are 1: Rejection, 2: Disregard, 3: Alienation, and 4: Actualization. In 

phenomenography it is impossible for one quotation to illustrate all aspects of the category 

described, but one appropriate quote can be selected which emphasizes the differences between 

categories, more than their commonalities.92 This study used a minimum of one and maximum 

of two quotes to emphasize difference. 

 

Category of Description 1: Rejection 

Rejection was the experience of students feeling unwanted in the community. It was most 

prominent during the pre-clinical years and carried into the clinical years in varying intensities. 

Students expressed conversations and experiences with educators which elicited feelings of 

rejection in the community. 

 



 

  
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“The one doctor said she never signed an agreement to teach students. And she said that 

blatantly in our face, and we’re like, were you never once a student?” 

Participant GECG15 

 

“The one doctor went so far as to question, she was basically, like, I don’t know why the university 

allows this whole graduate entry thing...and then in my mind, I’m just like, you’re basically 

questioning why I’m here.” 

Participant SBG12 

 

Category of Description 2: Disregard 

Disregard was the feeling of not being recognized by the community. It was experienced due to 

various events, from poor teaching efforts during the pre-clinical years to a complete lack of 

acknowledgement from clinical educators during the clinical years. 

 

“Many times, a consultant would come do the ward round with everyone there, no hello to us or 

anything, then once the round is over, they leave, without even recognizing we [students] are 

there. And that’s it”.  

Participant SBB14 

 

“To me it seemed like it was an additional duty of the clinician to deliver a lecture, but not 

necessarily a primary duty, or seen as a primary thing to be accomplished – or an important thing 

to be accomplished. More as a side thing”  

Participant SWB8                                                                                                           

Category of Description 3: Alienation 

Alienation was the experience of separation and isolation from the community. It was most 

pronounced during the pre-clinical years and continued in varying intensities in the clinical years.  

 



 

  
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“For me to be honest, Medical School is just not welcoming or friendly. During the pre-clinical 

years, you’re basically sitting in lecture theatres all day, then the clinical years are two years of 

feeling unwanted”. 

Participant SWG1 

 

There was always a lack of support until now. There’s always been this lacking… With each year, 

it might be in a different form but there’s always a lack of support. 

Participant SBG9  

 
Category of Description 4: Actualization 

This category expressed the collectives’ realization of symbolic access; three broad dimensions 

of variation contributed to this realization: 1. Relationships with peers, 2. Clinical skills teachings 

during the pre-clinical years (3rd and 4th year), 3. Clinical immersion and participation during the 

clinical years (5th and 6th year) (as per phenomenographic methods the researcher used a 

minimum of one and maximum of two quotes per dimension below)      

      

“… I always said that going to lectures and listening to a lecturer with your classmates is sort of 

like thinking, hey guys, we’re in this together.” 

Participant SBB14   

 
      

“And then, in 3rd and 4th year with clinical skills, I felt like the teaching was good and educators 

were very nice people. Very nice. They understood students, what students need, you know. So, 

I think clinical skills in 3rd and 4th year, we had good educators.” 

Participant SBG4 

 

“…I felt like they [clinical skills educators] were younger and they understood [us], I felt like they 

were very empathetic and understanding, or understood what students go through. They would 

make that extra effort.” 

Participant SWG1          

                                                                                                                                                                                                                                                                                                                    



 

  
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“It was very nice to be in the hospitals, to actually manage the patients, see the conditions that 

you’ve heard the theory about.” 

Participant SBB7 

 

“And then I did student internship. I thought that was really cool. I really enjoyed internship. I 

think the nice part of that was that for once there wasn’t such a focus on bedside tutorials and I 

was working with the team”. 

Participant SBB4 

 

 

Dimensions of Variation 

In phenomenography categories of description are experienced through dimensions of variation, 

dimensions are a collective of similar events found in the data. The five dimensions of variation 

discovered in this study were: 1. Interactions with Educators, 2. Relationships with Peers, 3. The 

Educational Environment, 4. Race and 5. Hierarchy. The interaction of these dimensions and the 

four categories expressed how students experienced symbolic access in the medical community       

is depicted in the Outcome Space. 

      

The Outcome Space 

The Outcome Space is the integration of the categories and dimensions, it gives a visual 

representation of how the phenomenon was experienced at a collective level. It can be 

represented as a diagram, table or figure. Three outcome space figures exist: hierarchal inclusive, 

with categories presented in taxonomy format, climatic, in which categories are arranged 

according to the level of the explanatory power, and chronological, which represents the 

development of the participants’ experience of the phenomenon.86,90  This study presents its 

outcome space in two ways, first using a chronological figure (Figure 4.2), this method shows the 

development of how participants experienced symbolic access. Initially, participants expressed 

limited experience of symbolic access but as they developed relationships with peers, attend 

clinical skills lessons and progressed to the clinical years, there is growing perception of the 



 

  
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phenomenon. The second representation is in a table format (Table 4.1), it gives a more detailed 

representation of the outcome space. A discussion of the outcome space will be elaborated in 

the discussion section. 

 

      

Figure 4.1: Chronological Outcome Space 



 

  
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Table 4.1: Tabular Outcome Space 

 

 

 

 

 

 



 

  
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Discussion 
Introduction 

The discussion brings ‘life’ to the study, it expresses the meaning of the data and findings, 

highlighting their importance and contribution to the particular field of study.93,94 This discussion 

chapter is divided into three parts; Part I: The Outcome Space, what does the data mean? Part II: 

Awareness of Symbolic Access: Do you feel like you’re part of the team? and Part III: How does 

symbolic access impact learning? These separate sections aim to unpack what was found in the 

outcome space, linking it to the research aims, objectives and literature. 

 

Part I: The Outcome Space, what does the data mean? 

We see two narratives described in the outcome space, the first major narrative is of exclusion, 

this was experienced through four categories of the outcome space: rejection, disregard, 

alienation and racial discrimination. These categories were perceived through the following 

dimensions of variation: interactions with educators, the educational environment and racism. 

The second minor narrative from the outcome space was of inclusion defined as actualization- 

the remaining category of description. Inclusion was primarily experienced through peer 

relationships, clinical skills lessons, hierarchy and clinical participation. The following paragraphs 

will expand in detail on how exclusion and inclusion were perceived, by merging the categories 

of description and dimensions of variation. 

 

Exclusion 

Interaction with Educators 

During the first four years of the programme educators and students engaged in a ‘transactional 

relationship’. This relationship consisted of educators delivering knowledge to the students, who 

in turn transacted this knowledge back to the lecturers in exams, no overt effort was made by 

educators to socialize students into the medical community or to develop relationships. Although 

students had the title of medical student, it did not translate to their lived experience and instead 

of developing community identity and belonging, students identified as general university 

students. The early medical years were cocoon-like, where students existed apart from the 



 

  
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community and had very limited opportunity to bond with their educators. The impact of these 

isolated pre-clinical years on the medical students’ sense of belonging, was the feeling of 

community legitimacy rooted in their ability to transact information successfully and progress 

academically.      

 

In the clinical years meaningful interactions with educators were fluctuant, explicit rejection and 

alienation were interspersed with sporadic episodes of recognition and inclusion. The teaching 

and learning atmosphere was largely shaped by the personality of consultants (most senior 

doctors in the unit) meaning these interactions were unpredictable and varied but were often 

expressed as predominantly exclusionary in nature. Students struggled to concretize 

relationships with senior educators, as interactions rarely went beyond scheduled one hour 

bedside tutorials. A significant amount of the students’ time was spent with less senior 

community members i.e., registrars, medical officers, or interns whose main objective was 

service delivery. Stark95 explains that the fragmented student-educator relationship found in the 

clinical setting is common, there are examples of high quality and inspirational interactions 

alongside deep humiliation and being made to feel unvalued.  

 

“In the actual hospitals I had some good experiences, Like in Obstetrics, I had a doctor,- he was 

so nurturing. He would like challenge you and then, in challenging you, it would inspire you to 

read more. Like, we found ourselves reading articles; I mean, who does that in GEMP 3? And then 

we found that we actually did really well because we were so interested and engaged. Even in 

the ward  round he made us a part of the team.” 

GECG15 

 

“…And we have had those experiences – [doctors] who can be quite… who criticise and actually 

are not shy to tell you that you’re stupid and incompetent, and I think that that doesn’t 

facilitate learning with our generation at all.” 

SWG5 



 

  
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“The learning environment is also shaped a lot by the consultant’s personality” 

SIB2 

In medical education relationships and socialization are fundamental for students; these events 

serve as the enculturation bridge for the ‘outsider’ into the community. Worley96 asserts that 

medicine cannot be learned without relationships, and curricula that ignore or take them for 

granted do so at their students’ peril. During the initial years of a university programme, the 

onus to structure, initiate and encourage academic relationships lies exclusively in the 

educator’s court, as they have the responsibility of creating the overt curriculum, and should be 

cognisant of the hidden curriculum.96 Lyon97 encourages established community members to 

have a clear and well-articulated view of the medical student’s role in the community, 

intentionally design curriculum and opportunities that provide accessible relationship platforms 

for the student.97,98  

 

Educational Environment 

Alienation from the community was described across two paradigms     , the physical environment 

and the educational climate.99, 100 Students’ experience of the physical environment mirrored 

their relational experience with educators, i.e., feelings of rejection and disregard and isolation. 

The entire first year of the programme was situated off medical school campus, the impact of 

this physical distance came across strongly as the students described their struggle to identify 

and associate with the medical community. Exclusion continued in subsequent years, 2nd -4th 

year, when students were again isolated from the medical community, as a large amount of their 

academic time was spent in didactic teaching lessons, which were delivered in the same lecture 

venue for an entire year. There was an expression of deep disappointment by these aspiring 

doctors to be, who found themselves confined to university spaces, while longing to be in clinical 

settings. 

 



 

  
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The outdated medical school building and infrastructure, which has remained unchanged for 

some 20 years- added to the feelings of neglect and isolation students felt, learners wondered 

why they were not deemed important enough for the community to create inspiring learning 

spaces. Nordquist et al101,102  state that the physical educational environment in higher education 

is a concern globally, explaining the scary realization that development of physical-learning 

spaces in higher education essentially stopped some 150 years ago. Very little effort is made on 

the part of medical faculties to create stimulating and appropriate learning environments for the 

medical student, who must self-negotiate these lifeless spaces together with experiences of 

separateness. 101,102 

 

The educational climate was primarily of the clinical years, the climate was described as 

unsupported and anxiety provoking. The complexity of managing a new learning environment 

and the clinical workload, coupled with poor support from clinical educators left students feeling 

alone and vulnerable. Kennedy et al103 describes the clinical setting as ruthless, autonomous, and 

stressful; newcomers are required to not only demonstrate their academic ability, but also the 

ability to work in an environment which contains literal life or death pressures. Shacklady104 and 

Ahmed105 confirm that the transition from pre-clinical to the full-on clinical environment 

increases anxiety levels for the medical student. Students have to deal with multiple new ‘hits’ 

at once and these factors generate high emotions, which are mostly negative. The complexity of 

this environment often leaves students feeling combinations of fear, anxiety and confusion. 104,105   

 

Race 

Experiences of racial discrimination uniquely moulded the Student of Colours’ (SoC) time in 

medical school, descriptions of race-based community exclusion was a repeated narrative. Social 

and academic alienation were described, as well as feelings of disconnect from the community 

culture. SoC’s told stories of favouritism towards certain race groups during teaching sessions, 

ward rounds and in examinations. There were deep feelings of being othered within the 

community. Few senior role models looked like the SoC, which made mentoring and a sense of 

relatability difficult for the SoC student in the community. SoC’s experienced two ‘exclusionary 



 

  
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hits’, the first SoC’s experienced broad alienation from being an outsider in a new community 

and second specific alienation being a medical student of colour in the community. Beagan106 

explains that medical schools are spaces where exclusion based on race is frequently described, 

students from racialised groups often describe mundane daily community practices which 

intentionally or unintentionally, other, exclude or alienate them. 

“So, race played a huge role in the exams. What would happen is, you know how we do our 

OSCEs. We only had one examiner, and most of them are white. There are only a few black 

examiners, from what I’ve seen.  I feel like some of them don’t believe a black person deserves 

to get an 80%. So, some people will just be like black people don’t really know much. Or as a black 

person you need to work very hard to prove yourself.” 

SBB7 

‘Some doctors would just come; they don’t say anything to black students. So, whenever they 

ask questions, [during ward rounds] they ask the white students. In my experience some of them 

focused more on the white students.” 

SBB14 

White participants did not discuss experiences based on race. Beagan106 explains this by stating 

that SoC’s often highlight their experience of racial exclusion for two reasons; it is their lived 

reality and the SoC is made acutely aware of their difference every day in the community. 

Literature highlights that most medical school culture caters largely for the White student, who 

more easily assimilates into its community and way of being. Despite its importance, there has 

been a noticeable lack of attention on how institutional racism is perpetuated by medical schools. 

Racist experiences are brushed off, culture remains and the profile of faculty members, 

particularly at senior levels, remains dominated by white staff, particularly men.107-112  

"The moment you walk [into] Medical School, the groups of people are just… It’s divided along 

racial lines” 

SBB14 



 

  
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… I noticed that you really get treated differently in terms of race. Like, on our first day. We are 

a group of three brown students – so we get there, and there was no introduction whatsoever. 

It was just like, oh hi, you’re the students, okay, let me show you where the stuff for bloods is… 

The following week, the GEMP… three students joined us and both of them were Caucasian. And 

the way they were greeted; there were like formal introductions and at each patient there was a 

short summary, or kind of an assessment thing – like this patient, this. And the whole week prior 

to that, we had not ever been acknowledged as being in the ward. 

GECG15 

 

Yes definitely. There weren’t many black doctors, actually. Within each block, maybe out of 20 

tuts, four would be from black doctors. Obviously, it’s different. Black doctors were usually nice 

but then you’d get those black doctors who were biased towards white people. 

SBG13 

 

“I’m just saying these racial biases that exist in the institution – I don’t know if it’s a consequence 

of the institution, but I would like to think that it’s more a consequence of the people within the 

institution. Like, you have certain people who still believe or horde those racial biases, so I’m not 

so sure how the university can change that” 

SBG12 

 

Unfortunately, negative experiences are not uncommon in medical education and are 

documented globally. The culture of student exclusion is ingrained, with recurring student stories 

of humiliation, dehumanization, and alienation from the medical community.113-115  

 

Inclusion 

The second minor narrative from the outcome space was of inclusion, i.e., the actualization of 

symbolic access. Inclusion was informed by peer relationships, clinical skills lessons, meaningful 

clinical immersion and participation, and hierarchy. 



 

  
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Peer relationships between student contemporaries and between senior and junior students was 

the first ‘welcome’ students received into the community. These informal relationships were a 

consistent source of inclusion and affirmation for students, functioning as encouraging support 

systems, both academically and socially. Eberle et al116 describe peer relationships in medical 

education as, a community of practice (CoP) within a CoP, explaining that through such essential 

relationship’s newcomers acquire vital knowledge of community culture and learn how to 

participate in the CoP in a meaningful way. Through intra-communities’ students were able to 

establish feelings of legitimacy in their new community. Junior students were ready to listen and 

participate when seniors shared knowledge of how to navigate faculty members’ expectations; 

and senior students were quick to share personal strategies of how to become successful 

academically and socially in the community.  

 

“When you go to Med School, you have to rely on your friends, I would say, to make the 

environment more lively and do well. I  think one of the good things about being in res is that 

you have too many connections, so even if your main group of friends are not there, there’s a 

lot more students that you know that you can get there, and because you know them, you 

know a lot more students after that.” 

SIB2 

 

“ A lot of them (senior students) had programmes where the older girls would teach the 

younger girls. And so, a lot of influence from the older people was what encouraged us to get 

help, because they said it was better getting help earlier and having someone who knows tell 

you what’s hard and what to expect. 

SBG10 



 

  
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“So, learning to figure out what they [doctors] like and what they don’t like. And it was a lot of 

word of mouth as well, because you had to ask other students from other hospitals what their 

consultant liked because you know that they examine you” 

GEWM5 

Additional data found that peer relationships could be marginally determinantal to students’ 

success, as participants described peer cliques based on race or religion in which academic 

resources were exclusively shared, leaving others out. This was a minor but noteworthy finding 

as it helped paint a comprehensive picture of both positive and negative aspects of peer 

relationships. Despite this peer relationships were found to be positive overall and added to 

feelings of acceptance for the student.  

 

“You can get academic information based on your race or religion, that’s why I tried to make 

friends across racial and religious lines. For example some past papers were in the ‘Black drive’ 

[which is for  Black students] and some Muslim students had other academic resources. So, it’s 

really about who you become friends with.” 

SIB2 

 

Clinical skills teaching sessions were deeply inclusionary and affirming sessions for the medical 

student. During these simulated lessons students learnt and participated in meaningful 

community traditions like wearing scrubs, using medical equipment and performing clinical 

examinations. This educational experience was coupled with positive community socialization 

with a consistent group of young clinical educators who taught the students, in small groups, 

every two weeks for two years, and who created an encouraging, safe and inclusive teaching 

environment. Hasan et al117 explain that the nature of clinical skills teaching lends itself to 

relationship development; small groups, interactive sessions, and continued guidance create a 

favourable climate for positive educator-student relationships. Medical students’ view clinical 

skills teaching as non-threatening and optimum, a time of strong affirmation from community 

educators. 95,117 These teaching sessions were the early foundation for symbolic access for these 



 

  
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students, as through these lessons’ students’ awareness of their medical identity began to take 

shape. 

 

Clinical immersion and meaningful participation in the clinical setting, both of which occurred 

during the final two years of the programme, were chief inclusion events. Being in the hospital, 

receiving bedside teaching, managing patients from admission to discharge, recognition during 

community events, and acknowledgement as junior colleagues from senior educators largely 

shaped students’ identity and boosted their sense of belonging within the community.  

 

Hierarchy as inclusion? 

While all other ‘inclusion events’ could be quickly explained, the experience of hierarchy as 

inclusion warranted deeper unpacking. The culture of hierarchy is a well-documented feature of 

medical communities and is much more evident in the clinical training environment where 

students have maximum interactions with community members. Upon entering the clinical 

environment students find themselves at the bottom of a very long and steep ladder of 

hierarchy.118,119 Despite it being experienced in a deeply negative way, hierarchy was understood 

as a form of initiation, that every medical student experiences in order to be deemed “tough 

enough to do medicine”. Ultimately it was seen by the students as a necessary experience to 

acquiring community inclusion.  

“…I think the suffering [laughing]…It makes you feel part of the team, too.” 

Participant SBG10 

 

“We all go through it [hierarchy] …We all have to go through it, of course, but it’s not always 

easy.” Participant SWG1 

 

For the medical student, the development of community identity is as a result of multiple events 

that are considered rites of passage in the community, these range from cadaver dissections to 

the wearing of white coat or the loss of one’s first patient.120-122 The experience of hierarchy 

functioned as an additional rite of passage for the participants, contributing to feelings of 



 

  
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inclusion and the evolution from student to junior doctor. Vanstone et al118,119 explain that 

hierarchy in medical education creates a social framework for the student, who can establish 

awareness of ‘their place’ in the community.  While exploring hierarchy as a form of inclusion the 

researcher notes that current literature explains events which lead to community inclusion but 

lacks exploring whether the essence of these events are negative or positive. Further research 

into this phenomenon is warranted but will not be explored for the scope of this study. 

 

Part II: Awareness of Symbolic Access: Do you feel like you are part of the team? 

In light of the outcome space’s double narrative further reflection of the interview data was 

required, the researcher sought to discover how this narrative related to students’ overall 

awareness of symbolic access. Deeper reflection revealed that despite deeply exclusionary 

experiences overall students recognize that they had gained symbolic access within the medical 

community. This awareness of symbolic access was revealed by the collective’s ability to identify 

with the community and its culture. In various ways students identified themselves as part of ‘the 

team’ or explained that they were confident of ‘their role’ in the community.  

 

Researcher: Do you feel like you’re part of the team? [medical community] 

[Chuckling] “For the most part yes, I do.” 

Participant GEWB5 

 

“Yes, in final year, in 5th year, they [seniors] aren’t really checking for you, but…final year, they 

really do make you feel like part of the team; well, in every rotation I’ve been in so far… “ 

Participant SBG10 

 

“I generally do. Like I understand what the job of an intern is. I understand it.” 

Participant SBG3 

 

Experiences which contributed towards the students’ awareness of symbolic access, included 

most of the events which facilitated their feelings of inclusion, namely: 1. Clinical Skills lessons 



 

  
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and educator relationships developed during these lessons, 2. Being in the hospital and receiving 

bed side teaching, 3. Managing their own patients, 4. Performing clinical skills in the hospital 

setting, 5. Working with future colleagues in the profession and 6. The experience of community 

hierarchy. Medical education literature emphasises that the main factors which contribute 

towards medical students’ sense of community belonging and professional identity include 1. 

Doing the work of the doctors, 2. Increased patient interaction, 3. Time spent in the hospital, 4. 

Being treated as healthcare workers, 5. Increased responsibility, and 6. Seeing their role models 

in action in the workplace.123  

 

In their educational theory, Situated Learning, Lave and Wenger theorise that within the medical 

setting the experience of community immersion and participation facilitates the development of 

community identity and belonging.116 These authors explain that in a CoP newcomer participation 

and the learning of community attributes such as vocabulary, skill, knowledge, and responsibility 

facilitate the newcomers progress from what they call a Legitimate Peripheral Participant (LPP), 

into a community member (Figure 5.1). They add that an important and concluding aspect of full 

participation in a CoP is the acquisition of the identity associated with the community.12,13,116 

 

 

               Figure 4.2: Progression of legitimate peripheral participant in community of practice12      

 



 

  
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Medical students articulate an awareness of symbolic access in the community, this awareness 

is facilitated through noteworthy events and experiences during the pre-clinical and clinical years 

such as clinical skills lessons, clinical immersion and participating meaningfully in the clinical 

setting. While strong negative events are experienced, these do not deter the awareness of 

symbolic access and can ironically contribute towards the awareness of it.  

 

Part III: How does symbolic access impact learning? 

During the pre-clinical years teaching was mass delivered didactically to classes of 300+ students, 

leaving little room for interactive and engaging learning opportunities. This teaching coupled with 

poor educator-student interactions resulted in student learning being defined as isolated, 

mentally overwhelming and disconnected from ‘real medicine’. One exception to the negative 

pre-clinical learning experience was clinical skills teaching and learning. These sessions were 

valued by the student body, who appreciated small group learning, and described the learning 

environment as supportive and conducive. 

“…I think in the earlier years I think it was more of self-study… [there was] not much interaction 

with lecturers”. 

Participant SWG1                                                                                                                                       

“…the people [educators in pre-clinical years] weren’t really approachable at all. They were just 

very mean and condescending, so it was like- now I just feel worse so why should I ask questions. 

It’s okay, I’ll YouTube that.”                                                                                                                                

Participant SBG13 

 

Clinical Skills Learning 

“…I do have some good experiences and I think I will start off with that. I think the [good] 

interactions that I had with the doctors were in Clinical Skills, I learned a lot because they were 

open to us and allowed for mistakes.” 

Participant SWG5 

 



 

  
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“I only spoke to the doctors during Clinical Skills and stuff. That was the only time I interacted 

with doctors. I felt like most of them were very helpful and I really learned a lot from them.” 

Participant SBB7 

 

Learning experiences during the clinical years were largely positive. Bedside teaching in smaller 

clinical groups with real life patients, experiential learning opportunities and clinical immersion 

bridged theory-practise gaps and created meaningful learning experiences for the students. 

Learning was tangible during the clinical years and contributed positive perceptions.  

 

“[The learning environment] is better, its more intimate because it isn’t a class with 300 anymore” 

Participant SWG1 

 

“The times when I’ve been taught at the bedside have been… I think some of them have been 

really the best learning experiences I’ve ever had, to be honest…those experiences are 

invaluable”. 

Participant SBB14 

 

“In clinical years now, we are in their [clinical educators] setting, they are more comfortable…you 

learn a lot from them, not only in terms of academics but just how to function.” 

Participant SIB2 

 

Clinical learning is said to be the cornerstone of medical education, as it is in this learning 

environment that students are able to participate in the medical community and develop both 

their clinical skills and professional identity. Medical students often perceive the tangible 

difference between the pre-clinical and clinical curriculums; and are able to articulate these 

changes in their learning due to the vast contrast of experiences. 124 

 

Learning that was valued during the pre-clinical years revolved around clinical skills lessons, 

during the clinical years valued learning included bedside teaching, clinical immersion and 



 

  
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meaningful clinical participation. The same events, which resulted in students' awareness and 

attainment of symbolic access, also resulted in students’ experience of meaningful learning 

experiences. Positive learning experiences were not described prior to being aware of or 

attaining symbolic access (Figure 5.2). Student learning was revived as they gained symbolic 

access, it facilitated the shift from disconnected, isolated and dead-end learning to applicable, 

contextual and transformative learning experiences. This study concludes therefore that 

attaining symbolic access is strongly connected with positive learning experiences for the medical 

student. 

 

 

Figure 4.3: Students Perceptions of Learning with and without awareness of Symbolic Access 

In conclusion, unpacking how the outcome space related to symbolic access brought to light 

some interesting discussion points. While experiences of student rejection, alienation and 

exclusion remain prominent in the medical community, the medical student is able to articulate 

an actualization of symbolic access. Some negative community events even act as facilitators for 

symbolic access. 

 

 

 

 

 

 

 



 

  
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Chapter Five: Conclusion 
 

The study of how students become aware of and gain institutional culture in higher education 

has not been adequately explored or articulated within the South African context.38,39 Introducing 

the concept of symbolic access to institutional culture ‘opened up’ an alternative exploration 

route for institutional culture, allowing the researcher to discover and describe experiences 

which facilitate awareness and attainment of symbolic access to institutional culture for the 

medical student.   

 

This research discovered that in medical education, symbolic access to institutional culture 

functions as a ‘key’ which unlocks meaningful learning experiences and professional identity 

development for the medical student. In addition, it discovered that symbolic access is influenced 

both by positive and negative community encounters. Medical educationalists are encouraged 

to design undergraduate curricula with intentionality, focusing on promoting educator-student 

interactions, early community socialization and early clinical immersion, as these factors are 

linked to the attainment of symbolic access and meaningful learning. 

 

 

Introducing and exploring symbolic access in medical education holds value as it required delving 

into intangible, yet influential concepts which impact the medical community. This research adds 

to discussions around qualitative factors that influence student learning and contributes to 

scholarship of sociocultural factors which impact learning in South African medical and higher 

education. 

 

Study Limitations 

This study was conducted in one medical school setting, making the findings contextual, however 

the findings linked with literature from other settings. There was scarcity of prior research on the 

phenomenon under investigation, which warranted the investigation but also meant there was 

minimal literature to support and elaborate on the phenomenon. The study methodology 



 

  
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chosen, phenomenography, was labour and time intensive. The study sample could not be 

purposively selected, however convenience sampling resulted in the appropriately diverse 

sample. Although the sample size was within acceptable limits for phenomenographic study a 

larger sample size may have added more variation of phenomenon experiences. 

While categories were based on words of the participants, the researcher confirms that the 

interpretation of these words was influenced by the philosophies and interests of the researcher, 

as the researcher undertook the study due to her interest in the topic. The involvement of the 

researchers meant that data could not interpret itself or be completely without the bias of the 

researchers, who developed the categories of description. Readers and researchers are therefore 

open to scrutinize the categories based on the data given and arrive at a different interpretation. 

 

However, research is a mutual space, shaped by both researcher and participants, hence both 

identities have the potential to influence the entire research process.74 While researcher 

interpretations were used when analysing the data only interpretations supported by the data 

were retained.  Marton suggested that the categories of description relate the collective rather 

than individuals57,76 therefore it can be argued that this collective includes the researchers as 

they conceptualised the research, participated and shaped the interview and the data. While the 

researchers voice is not explicit in participant transcripts, the researchers do influence the 

participants' voice. 

 

Recommendations      
Using phenomenography as a foundation was fundamental to this research, its pedagogical focus 

means that the discoveries of this study can be used as recommendations to bridge the gap 

between research and pedagogy.125 The following recommendations are informed by the 

discoveries of this study. 

 

 

 



 

  
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Recommendation 1 

A review and redesign of the pre-clinical curriculum in the medical programme, with specific 

focus on implementing pedagogy that increases student-educator interactions during the first 

four years of the academic programme. The main aim should be to create meaningful learning 

opportunities for the students and promote early educator-student relationship development. 

The current Clinical Skills teaching model functions as an example and template towards this 

recommendation. 

 

Recommendation 2 

Review and re-design of the medical curriculum to include early ongoing clinical exposure in the 

form of longitudinal clinical clerkships, which spiral from the pre-clinical years (1st-4th) into the 

clinical years (5th-6th) of the programme. The design of these clerkships should include staggered 

clinical immersion which increases as students’ progress from year to year. 

 

Recommendation 3 

Constructional redesign of the physical learning environment (physical learning spaces both 

within and outside of scheduled class time: the classroom and campus), in order to create 

learning environments which, achieve the promotion of learner centred, interprofessional 

education. This process needs to be facilitated by key roles players namely faculty management, 

educationalists, architects and students. 

 

Recommendation 4 

Scheduled regular individual or group discussions between Students of Colour and 

educators/staff in management with the specific intent of learning about and acknowledging the 

student’s lived experience. From these engagements, staff and educators should work with these 

students towards the co-creation of an inclusive medical school curriculum, culture, and 

environment, with which      Students of Colour resonate and identify. Students of colour need 

to see themselves represented in the curriculum, amongst peers, and faculty, the failure to 



 

  
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recognize themselves in the community, will continually leave the SoC with a feeling of deep 

alienation.  

 

Recommendation 5 

Further scholarship of symbolic access in medical education and higher education, in order to 

extend understanding of this phenomenon and deepen our understanding of its pedagogical 

impact. Symbolic access is a new and developing concept, this study has shown that it is a factor 

that influences student learning in medical education. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 

  
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