Clinical Teaching Fellow Practice Within Complex Clinical–Educational Systems: An Activity Theory–Informed Case Study

BACKGROUND: Clinical teaching occurs where patient care and education coexist. Within the United Kingdom's National Health Service, workforce pressures constrain teaching and supervision. Clinical Teaching Fellow (CTF) roles have expanded in response but are often viewed as discrete posts rather than practices situated within complex clinical-educational systems. This study examined how tensions within and across these systems shaped CTF practice. METHODS: This theory-informed exploratory qualitative case study used third-generation Activity Theory. All 10 members of a hospital medical education team were invited to a semistructured group interview; eight participated. An Activity Theory-informed thematic approach was used to map the focal undergraduate clinical education activity system and examine tensions within it and at its intersections with adjacent systems. FINDINGS: Participants included three CTFs, two education facilitators and three administrators. CTF practice involved teaching, programme coordination and administrative work within a multiprofessional team. Differing understandings of the activity's purpose and outcomes shaped practice. Professional language, continuity, experience and blurred divisions of labour influenced participation and work organisation. Relationships with clinical services, the medical school, postgraduate medical education and university-based postgraduate study introduced competing demands. Participants negotiated tensions through communication, redistribution of responsibilities and closer working across professional roles. CONCLUSIONS: CTF roles are embedded within systems where educational, clinical and organisational priorities intersect. Third-generation Activity Theory makes visible how relationships within and across these systems shape practice. Supporting CTF roles requires attention to how educational work is organised, coordinated and prioritised.