Recognising the importance of the education environment

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18 Recognising the importance of the education environment

This neglected area is now recognised as being a substantial and very real element that influences students’ learning. Tools are available to assess the education environment.

What is the learning environment?

We can read the curriculum documents, we can inspect the expected learning outcomes, and we can experience a wide range of teaching approaches, but we may know little about the student’s experience in the education programme. Key to this, suggests Genn (2001), is the atmosphere or climate experienced by the student in the school – what is valued, what is recognised and what is encouraged. As Genn describes, the education climate is the soul and heart of the medical school. It is the education environment that determines the students’ behaviour, their achievements and their satisfaction. McAleer et al (2009) likened it to the climate or environment in the meteorological context and suggested that we cannot hope to maximise the education output if we do not foster a nurturing climate.

Contributing to the learning environment in a medical school or a postgraduate programme and influencing the students’ or trainees’ learning, positively or negatively, are:

• how students are taught and the education strategies adopted

• what they are taught

• how they are assessed

• the types of clinical experiences offered

• the books and resources available online or in the library

• the values expressed by their teachers

• physical factors such as lecture theatre seating, heating, cooling and levels of noise.

The education climate is important

The establishment of an appropriate climate is almost certainly the most important single task for a medical teacher. Genn and others have highlighted that while the education climate may seem rather intangible, unreal and insubstantial, its effects are pervasive, substantial, very real and influential. The climate, it has been suggested, is like a mist – you cannot stay long in the mist before being thoroughly soaked. The climate includes the type of things that are rewarded, encouraged and emphasised, and the style of life that is valued in the school or training programme. A study of the learning environment can help to answer questions such as these:

• In the medical school or training programme is collaboration or competition between students encouraged?

• Is the student encouraged to ask questions and think creatively or to participate passively and follow the rules?

• Is the curriculum about meeting the needs of the learner or the needs of the teacher?

• Does the curriculum challenge and stretch students or require only minimum competence?

• Is the environment a trusting one where the teacher is supportive and tolerant of mistakes or is the teacher viewed with suspicion as the ‘enemy’ of the student?

Without an examination of the education environment these questions go unanswered. Genn (2001) suggests “If we wish to describe, assess, or otherwise ‘get a handle on’ the curriculum in a medical school, we need to consider the environment, educational and organisational, associated with the curriculum and the medical school”.

In postgraduate training particular concerns have related to poor supervision, variable and unpredictable teaching, lack of continuity, the provision of feedback that is not constructive, and an emphasis on service requirements rather than educational requirements. These can all be related to the established education environment.

Suggestions that students become more cynical and less empathetic as they progress through the medical curriculum are a cause of concern. The problem may rest, at least in part, with the education environment. Too often this is task orientated with the emphasis on the presentation by an expert scientist or clinician who knows the answers and procedures while the social– emotional orientation concerning the development of a caring helper of sick people is neglected. An appropriate education environment should encourage the development of abilities to empathise and identify with patients and their predicaments.

The need for a fundamental review of medical education was proposed by the Global Independent Commission on Education of Health Professionals for the 21st Century published in The Lancet in December 2010. The recommendations proposed far-reaching changes to learning outcomes and to methods of teaching, learning and assessment and addressed issues relating to teamwork, inter-professional collaboration, international dimensions and individualised learning. One could argue that key to the implementation of these changes is the development of a supportive education environment.

Aspects of the education environment

The medical education environment is extraordinarily complex. The different dimensions are sometimes referred to as orientations. Some aspects or orientations of the environment that merit consideration are listed here. The list is not comprehensive but it provides examples of the various orientations.

Collaborative or competitive orientation

It is a paradox that while teamwork and collaboration are identified as important learning outcomes in medical training and the importance of the inter-professional team is recognised, the training programme with which our students and trainees engage fosters competition rather than collaboration. Students are recognised and rewarded on the basis of their individual performance and not on their performance as a member of a team or group.

A collaborative education environment is created and students develop a feeling of ‘belonging’ in the group or team if they are encouraged to work with their colleagues and to participate as part of a ward team in clinical attachments. In PBL curricula there have been attempts to value and assess group performance.

Student or teacher orientation

The education environment may be one in which the teacher is more valued than the student. In a student-centred environment what is valued is the learner, and their interests and student independence and autonomy are encouraged, as discussed in Chapter 13.

Supportive or punitive orientation

Students or trainees in the past have been left to their own devices to deal with academic or personal problems. Some students have found the teaching threatening or intimidating, especially if they have been humiliated or harassed. Such an environment has been seen as helping to toughen the student with survival seen as some sort of rite of passage. Learners were encouraged to cover up any difficulties experienced or refrain from divulging gaps in their knowledge. More recently the climate has changed. Students are encouraged to assess their own progress and identify any difficulties they might have with the assurance that support and counselling are available. In a supportive education environment learners are free to experiment, voice their concerns, identify their lack of knowledge and stretch their limits.

Community or hospital orientation

Medical education has been criticised as having as its base an ivory tower academic centre, distant from the realities of the day-to-day practice of family medicine in the community. Professors and specialists with international recognition are the role models for the students. It is perhaps not surprising that, in the past, a career in general practice or in a rural community was frowned on by students as being a ‘second best’ choice. Fortunately this tension has now been recognised and there is a greater emphasis on students learning in the community and in the rural setting with some medical schools established in a rural location.

Research or teaching orientation

The teaching and learning programme may be one that is conducted in the context of an environment where research is valued and rewarded, and where teaching is seen as an activity that encroaches on writing research papers or proposals for funding. Some medical schools are trying to redress the balance by recognising the scholarship of teaching as a criterion for appointments and promotions. Newly appointed faculty members may be expected to demonstrate or acquire, through a staff development programme, expertise in teaching.

The effects of the environment

The educational climate may manifest itself in a number of ways:

• The education environment makes a unique and notable contribution to the prediction of student achievement and success.

• The motivation of the learner is influenced by the education environment in which he or she is studying.

• Many factors influence career choice but undoubtedly the education environment can have a significant impact. Preference for a career as a surgeon in an academic centre, or for a career as a general practitioner in a rural community, may be attributed to the education environment in the training programme.

• Staff may be more inclined to stay in a post if an institution has a good education environment. It is easier to attract new staff to such an institution.

Assessment of the education environment

One reason why the education environment was ignored in the past was the lack of a suitable instrument or tool to measure it. A number of validated instruments are now available for use in different settings. McAleer et al (2010) described 30 such tools and provided a useful summary of tools available. Those most frequently used are the Dundee Ready Education Environment Measure (DREEM) and the Postgraduate Hospital Educational Environment Measure (PHEEM).

The education environment can be assessed using qualitative as well as quantitative approaches. A qualitative approach involves collecting data using a survey instrument with open-ended questions such as ‘What do you most like about your training programme?’, or by eliciting feedback from focus groups. With quantitative instruments students are asked to reply to a series of questions with each question relating to one aspect or dimension of the education environment.

DREEM has five subscales as described in Appendix 12:

1. students’ perceptions of learning

2. students’ perceptions of teachers

3. students’ academic self-perceptions

4. students’ perceptions of atmosphere

5. students’ social self-perceptions.

DREEM contains 50 statements covering these dimensions with a 5-point scale for each item scored from 0 for ‘strongly disagree’ to 4 for ‘strongly agree’. There is a maximum score of 200 indicating the ideal education environment as perceived by the student. Excellence is indicated by a score of 151–200.

Instruments have been developed to assess the education environment in postgraduate education (PHEEM), in the anaesthetic theatre (ATEEM) and in the surgery theatre (STEEM) (Roff 2005).

The use of environment measures

Measurements of the education environment can be used to:

• establish the profile for an institution and gain a holistic view of the curriculum

• understand students’ perceptions of the education environment they have experienced and compare it with their perception of the ideal environment

• compare the perceptions of the different stakeholders including staff, students and managers

• compare the environment as it exists in different departments or attachments within a school and at different phases of the training programme

• provide the medical school or postgraduate body, as a ‘learning organisation’, with an indication of what may be lacking in their programme and where change may be necessary, while at the same time nurturing aspects where no change is required

• assess the effect of a change made in the curriculum, comparing the education environment before and after the change

• compare the environment of different medical schools or geographical settings.

Conclusions

The education climate or environment is a key factor in the success of an undergraduate or postgraduate education programme. Measurement of the education environment provides valuable information relating to curriculum planning and evaluation. Quality assurance of education programmes involving all the stakeholders is on today’s agenda. A pertinent and topical angle on this is the measurement of the education environment. Curriculum change may fail because changes have been made to the timetable, the teaching and learning methods and the assessment but without consideration being given to the education environment.

Reflect and react

1. Think about what type of learning environment you would wish to have as a student and how this compares with the environment that exists in your training programme.

2. If information is not already available, measure the education environment in your teaching situation using one of the tools available. On the basis of the results think about how the programme could be improved.

3. Reflect on how your own teaching and attitudes contribute to the education environment as perceived by students or trainees.

Exploring further

If you have a few hours

Genn J.M. Curriculum, environment, climate, quality and change in medical education – a unifying perspective. AMEE Medical Education Guide. No. 23. Med. Teach.. 2001;23:445-454.

A key text on the subject that merits careful reading.

Hoff T.J., Pohl H., Bartfield J. Creating a learning environment to produce competent residents: the roles of culture and context. Acad. Med.. 2004;79:532-540.

Ideas from management theory helped the authors identify attitudes, behaviours and interactions that define a learning culture.

Holt M.C., Roff S. Development and validation of the Anaesthetic Theatre Educational Environment Measure (ATEEM). Med. Teach.. 2004;26:553-558.

A description of how the measure was developed and how it is capable of identifying problem areas that can be remediated.

McAleer S., Soemantri D., Roff S. Educational environment. In: Dent J.A., Harden R.M., editors. A Practical Guide for Medical Teachers. third ed. London: Elsevier; 2009:64-70. (Chapter 9).

Roff S. Education environment: a bibliography. Med. Teach.. 2005;27:353-357.

A list of over 100 relevant articles.

Roff S., McAleer S., Harden R.M., et al. Development and validation of the Dundee Ready Education Environment Measure (DREEM). Med. Teach.. 1997;19:295-299.

The first description of this important inventory.

Roff S., McAleer S., Skinner A. Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK. Med. Teach.. 2005;27:326-331.

A description of the development of the Postgraduate Hospital Educational Environment Measure (PHEEM).

Shobhana N., Wall D., Jones E. Can STEEM be used to measure the educational environment within the operating theatre for undergraduate medical students? Med. Teach.. 2006;28:642-647.

The Surgical Theatre Educational Environment Measure was shown to be a reliable and practical tool for measuring the operating theatre educational environment.

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