Development of an instrument to measure the clinical learning environment in diagnostic radiology

Selecting Instruments for Measuring the Clinical Learning Environment of Medical Education: A 4-Domain Framework

Learning environments shape the experiences of learners and practitioners, making them an important component of program evaluation. However, educators find it challenging to decide whether to measure clinical learning environments with existing instruments or to design their own new instrument and, if using an existing instrument, which to choose. To assist educators with these decisions, the authors compared clinical learning environment instruments based on their characteristics, underlying constructs, and degree to which items reflect 4 domains (personal, social, organizational, material) from a recently developed model for conceptualizing learning environments in the health professions. Building on 3 prior literature reviews as well as a literature search, the authors identified 6 clinically oriented learning environment instruments designed for medical education. They collected key information about each instrument (e.g., number of items and subscales, conceptual frameworks, operational definitions of the learning environment) and coded items from each instrument according to the 4 domains. The 6 instruments varied in number of items, underlying constructs, subscales, definitions of clinical learning environment, and domain coverage. Most instruments focused heavily on the organizational and social domains and less on the personal and material domains (half omitted the material domain entirely). The variations in these instruments suggest that educators might consider several guiding questions. How will they define the learning environment and which theoretical lens is most applicable (e.g., personal vitality, sociocultural learning theory)? What aspects or domains of the learning environment do they most wish to capture (e.g., personal support, social interactions, organizational culture, access to resources)? How comprehensive do they want the instrument to be (and correspondingly how much time do they expect people to devote to completing the instrument and how frequently)? Whose perspective do they wish to evaluate (e.g., student, resident, fellow, attending, team, patient)? Each of these considerations is addressed.

An Analysis of the Educational Environment at the Malta Foundation Programme Using the Postgraduate Hospital Educational Environment Measure (PHEEM)

BACKGROUND

Learning from managing patients in a real-world context is by far superior to simulation learning. A substandard educational environment is associated with poor patient care and suboptimal learning outcomes. The measurement of the educational environment provides insight into what is needed to improve the level of training.

OBJECTIVE

To measure the educational environment as perceived by trainees within the Malta Foundation Programme.

METHODS

This study used the Postgraduate Hospital Educational Environment Measure (PHEEM) to measure the educational environment at the Malta Foundation Programme. Descriptive statistics were used to describe the demographics of the study population. Nonparametric comparative statistics were used to identify statistically significant differences between groups.

RESULTS

Ninety-eight trainees out of 370 (26.5%) completed the online questionnaire. These consisted of 39 FY1s (31.5% of 124), 33 FY2s (24.8% of 133), and 26 extended FYs (23.0% of 113). The 40-item PHEEM showed good reliability with a Cronbach's α value of .912. These doctors perceived their educational environment as more positive than negative. Perceptions are worst among trainees at the end of their first year of training. Those who had just finished their training have reported better perceptions. The 3 worst scoring items are related to when the trainees are on call.

CONCLUSION

Among trainees within the Malta Foundation Programme, perceptions of role autonomy and social support are areas where most work is needed. Teaching seems to be moving in the right direction, but there is always room for improvement.

Adaptation and initial examination of the psychometric properties of the Short Supervisory Relationship Questionnaire (SSRQ) for use with general practice registrars

The relationship between general practice (GP) registrars and their supervisors underpins the training experience for the next generation of medical practitioners. Building on recent research into the development and validation of a measure of the relationship between registrars and supervisors from the perspective of the supervisor, the current study focuses on the educational alliance from the perspective of the registrar. This paper presents an adaptation and initial validation of the clinical psychology supervisory relationship measure for GP registrars in an Australian context. Following an Expert Group review and adaptation of the items, 238 GP registrars completed the adapted tool. Using exploratory factor analysis and Procrustes confirmatory rotation, an optimal four factor model of the supervisory relationship was identified, reflecting measures of Safe base (α =.93), Supervisor investment (α =.96), Registrar professionalism (α =.90), and Emotional intelligence (α =.87). The general practice supervisory relationship measure for registrars (GP-SRMR) demonstrated excellent model fit, high internal consistency, and was theoretically consistent with the original tool. Implications for clinical education and future research are presented.

An optimal environment for placement learning: listening to the voices of speech and language therapy students

BACKGROUND

Placements are a core component of learning within speech and language therapy (SLT) undergraduate and postgraduate university programmes. They facilitate the development of students' professional and clinical competencies and socialization into the profession. It is indicated that an optimal environment for placement learning often pivots on the mentoring, supervision and feedback the student receives.

AIMS

To explore the perspectives of student SLTs in the Republic of Ireland in relation to factors that would best support their learning and competency development on placement.

METHODS & PROCEDURES

Qualitative data were collected from an anonymous online student survey that consisted of eight open-ended questions. Thematic analysis was applied to the data. Excerpts from the data were selected to illustrate the themes constructed.

OUTCOMES & RESULTS

A total of 117 students responded. Four salient themes were generated that capture the students' perspectives of an optimal environment for placement learning and competency development.

CONCLUSIONS & IMPLICATIONS

This study supports quality assurance within the practice education of student SLTs and highlights aspects of an optimal learning environment that practice educators can strive to develop. In parallel, this study points to the need for improved supports from university personnel and placement site managers, and an increased need for student preparedness and self-reflection. Implications for continuing professional development specific to the role of a practice educator is described, in addition to the recommendation of an expanded perspective of supervision within SLT. What this paper adds What is already known on the subject Placements are an integral component of SLT undergraduate and postgraduate university programmes that enable students to translate theory to practice. Placement involves a transition from structured and predictable learning of the classroom to more dynamic learning environment within the placement site. Assessment of placement is carried out by practice educators using competency assessment tools. An optimal environment for placement learning often pivots on the mentoring, supervision and feedback that the student receives from their practice educator. What this paper adds to existing knowledge This study explores student SLTs' voices in relation to what they consider an optimal environment for placement learning should be and what they believe may best support them in their journey to develop their clinical competencies. It supports quality assurance of the practice education of our future colleagues. What are the potential or actual clinical implications of this work? The findings of this enquiry emphasize the distinction between competence as a SLT and competence as a practice educator and have subsequent implications for the content of continuing professional development for practice educators. In particular, an expanded perspective of the models and frameworks of supervision to promote and implement within the practice education of SLT students is presented.

Adapting the supervisory relationship measure for general medical practice

BACKGROUND

The relationship between general practice (GP) supervisors and registrars is a critical component in effective training for the next generation of medical practitioners. Despite the importance of the relational aspect of clinical education, most evaluation has traditionally occurred from the perspective of the registrar only. As such, no validated tools exist to measure the quality of the supervisory relationship from the perspective of the supervisor. This paper presents an adaptation and validation of the clinical psychology supervisory relationship measure (Pearce et al, Br J Clin Psychol 52:249-68, 2013) for GP supervisors in an Australian context.

METHOD

Following an Expert Group review and adaptation of the items, 338 GP supervisors completed the adapted tool.

RESULTS

Using principal components analysis and Procrustes confirmatory rotation, an optimal three-component model of supervisory relationship was identified, reflecting measures of Safe base (α = .96), Supervisor investment (α = .85), and Registrar professionalism (α = .94).

CONCLUSIONS

The general practice supervisory relationship measure (GP-SRM) demonstrated excellent model fit, high internal consistency, and was theoretically consistent with the original tool. Implications for clinical education and future research are presented.

The clinical learning environment in nursing education: a concept analysis

AIM

The aim of this study was to report an analysis of the clinical learning environment concept.

BACKGROUND

Nursing students are evaluated in clinical learning environments where skills and knowledge are applied to patient care. These environments affect achievement of learning outcomes, and have an impact on preparation for practice and student satisfaction with the nursing profession. Providing clarity of this concept for nursing education will assist in identifying antecedents, attributes and consequences affecting student transition to practice.

DESIGN

The clinical learning environment was investigated using Walker and Avant's concept analysis method.

DATA SOURCES

A literature search was conducted using WorldCat, MEDLINE and CINAHL databases using the keywords clinical learning environment, clinical environment and clinical education. Articles reviewed were written in English and published in peer-reviewed journals between 1995-2014.

METHODS

All data were analysed for recurring themes and terms to determine possible antecedents, attributes and consequences of this concept.

RESULTS

The clinical learning environment contains four attribute characteristics affecting student learning experiences. These include: (1) the physical space; (2) psychosocial and interaction factors; (3) the organizational culture and (4) teaching and learning components. These attributes often determine achievement of learning outcomes and student self-confidence.

CONCLUSION

With better understanding of attributes comprising the clinical learning environment, nursing education programmes and healthcare agencies can collaborate to create meaningful clinical experiences and enhance student preparation for the professional nurse role.

Development and validation of the AMEET inventory: An instrument measuring medical faculty members' perceptions of their educational environment

We developed, through a three-round modified Delphi technique, an inventory [Assessment of Medical Education Environment by Teachers (AMEET)] to assess viewpoints of medical faculty on educational environment experienced by teachers. In Round 1, 16 members from international settings graded (0-3) and modified an initial list of statements, or suggested new statements for inclusion. In Round 2, the new statements were graded and previous responses reconsidered. Subsequently, statements with median scores ≤1 were excluded. The questionnaire was compiled following reconsideration of responses to new statements in Round 3. A pilot test enabled assessment of the validity and reliability of the instrument. The panel members modified and graded the initial 50 statements of the preliminary inventory and suggested five new statements. The new statements were graded, responses to previous 50 statements were reconsidered, and three statements with median scores <1 were removed following Round 2. On review of the 52 statements by panel, two statements (each with agreement of <75%) were deleted. The final 50-item inventory comprising six domains was piloted with 62 faculty. Cronbach's alpha of 0.94 was obtained. The AMEET inventory is valid, highly reliable and practically useful to assess medical faculty members' perceptions of educational environment.

Measuring the clinical learning environment in anaesthesia

The learning environment describes the way that trainees perceive the culture of their workplace. We audited the learning environment for trainees throughout Australia and New Zealand in the early stages of curriculum reform. A questionnaire was developed and sent electronically to a large random sample of Australian and New Zealand College of Anaesthetists trainees, with a 26% final response rate. This new instrument demonstrated good psychometric properties, with Cronbach's α ranging from 0.81 to 0.91 for each domain. The median score was equivalent to 78%, with the majority of trainees giving scores in the medium range. Introductory respondents scored their learning environment more highly than all other levels of respondents (P=0.001 for almost all comparisons). We present a simple questionnaire instrument that can be used to determine characteristics of the anaesthesia learning environment. The instrument can be used to help assess curricular change over time, alignment of the formal and informal curricula and strengths and weaknesses of individual departments.

Assessing medical students' and residents' perceptions of the learning environment: exploring validity evidence for the interpretation of scores from existing tools

PURPOSE

Although most agree that supportive learning environments (LEs) are essential for effective medical education, an accurate assessment of LE quality has been challenging for educators and administrators. Two previous reviews assessed LE tools used in the health professions; however, both have shortcomings. The primary goal of this systematic review was to explore the validity evidence for the interpretation of scores from LE tools.

METHOD

The authors searched ERIC, PsycINFO, and PubMed for peer-reviewed studies that provided quantitative data on medical students' and/or residents' perceptions of the LE published through 2012 in the United States and internationally. They also searched SCOPUS and the reference lists of included studies for subsequent publications that assessed the LE tools. From each study, the authors extracted descriptive, sample, and validity evidence (content, response process, internal structure, relationship to other variables) information. They calculated a total validity evidence score for each tool.

RESULTS

The authors identified 15 tools that assessed the LE in medical school and 13 that did so in residency. The majority of studies (17; 61%) provided some form of content validity evidence. Studies were less likely to provide evidence of internal structure, response process, and relationship to other variables.

CONCLUSIONS

Given the limited validity evidence for scores from existing LE tools, new tools may be needed to assess medical students' and residents' perceptions of the LE. Any new tools would need robust validity evidence testing and sampling across multiple institutions with trainees at multiple levels to establish their utility.

Key elements in assessing the educational environment: where is the theory?

The educational environment has been increasingly acknowledged as vital for high-quality medical education. As a result, several instruments have been developed to measure medical educational environment quality. However, there appears to be no consensus about which concepts should be measured. The absence of a theoretical framework may explain this lack of consensus. Therefore, we aimed to (1) find a comprehensive theoretical framework defining the essential concepts, and (2) test its applicability. An initial review of the medical educational environment literature indicated that such frameworks are lacking. Therefore, we chose an alternative approach to lead us to relevant frameworks from outside the medical educational field; that is, we applied a snowballing technique to find educational environment instruments used to build the contents of the medical ones and investigated their theoretical underpinnings (Study 1). We found two frameworks, one of which was described as incomplete and one of which defines three domains as the key elements of human environments (personal development/goal direction, relationships, and system maintenance and system change) and has been validated in different contexts. To test its applicability, we investigated whether the items of nine medical educational environment instruments could be mapped unto the framework (Study 2). Of 374 items, 94% could: 256 (68%) pertained to a single domain, 94 (25%) to more than one domain. In our context, these domains were found to concern goal orientation, relationships and organization/regulation. We conclude that this framework is applicable and comprehensive, and recommend using it as theoretical underpinning for medical educational environment measures.

Practice education learning environments: the mismatch between perceived and preferred expectations of undergraduate health science students

BACKGROUND

Practical hands-on learning opportunities are viewed as a vital component of the education of health science students, but there is a critical shortage of fieldwork placement experiences. It is therefore important that these clinical learning environments are well suited to students' perceptions and expectations.

PURPOSE

To investigate how undergraduate students enrolled in health-related education programs view their clinical learning environments and specifically to compare students' perception of their 'actual' clinical learning environment to that of their 'preferred/ideal' clinical learning environment.

METHOD

The Clinical Learning Environment Inventory (CLEI) was used to collect data from 548 undergraduate students (55% response rate) enrolled in all year levels of paramedics, midwifery, radiography and medical imaging, occupational therapy, pharmacy, nutrition and dietetics, physiotherapy and social work at Monash University via convenience sampling. Students were asked to rate their perception of the clinical learning environment at the completion of their placements using the CLEI.

RESULTS

Satisfaction of the students enrolled in the health-related disciplines was closely linked with the five constructs measured by the CLEI: Personalization, Student Involvement, Task Orientation, Innovation, and Individualization. Significant differences were found between the student's perception of their 'actual' clinical learning environment and their 'ideal' clinical learning environment.

CONCLUSION

The study highlights the importance of a supportive clinical learning environment that places emphasis on effective two-way communication. A thorough understanding of students' perceptions of their clinical learning environments is essential.