Hosting Displaced Medical Students in Times of Crisis: A Multi-National Qualitative Study Advancing the Consolidated Framework for Implementation Research (CFIR)

Catastrophic geopolitical conflicts increasingly disrupt the continuity of global medical education, placing immense pressure on clinical training pipelines and forced-migration student groups. While short-term, reactive, remote learning models exist, there are a profound lack of evidence-based implementation templates for medical schools within stable host nations to systematically host and integrate displaced clinical student cohorts mid-stream. This study explores the multi-level barriers and facilitators to hosting displaced medical students across diverse international environments, seeking to establish a rigorous, scalable model of educational sanctuary while advancing implementation science theory in crisis contexts. Employing a qualitative multi-site case study design guided by a critical realist ontology, this study analysed 66 semi-structured interviews with displaced Gazan medical students, hosting lecturers, clinical coordinators, and support staff across the United Kingdom, Malaysia, Pakistan, Turkey, and South Africa, mapping reflexive thematic analysis findings onto the Consolidated Framework for Implementation Research (CFIR). The analysis revealed that while rigid immigration policies, clinical placement caps, and severe cultural distance represent substantial barriers, key facilitators include assessment considerations, flexible placement models, sanctuary institutional cultures, peer networks, and decentralised administrative trust. Strategic administrative approaches, such as classifying displaced students as extended clinical elective visitors rather than full-time matriculants, enabled institutions to accommodate them within existing frameworks. This study demonstrates that public sector higher education institutions can act as vital global sanctuary networks to preserve clinical training pipelines. Crucially, the findings advance implementation science by proposing three novel constructs for the updated CFIR in crisis environments: Agile Implementation Over Perfection within the Implementation Process domain, Protective Leadership Shielding within the Inner Setting domain, and Bidirectional Boundary Subversion at the Inner/Outer Setting interface. This theoretical refinement transforms CFIR from a determinant model for stable, clinical interventions into an active, equity-driven framework for rapid humanitarian response in politically contested environments.