Exploring Clinical Learning Environments for Postgraduate Medical Education & Training A Group Concept Mapping study Principal Investigator: Dr. Deirdre Bennett PhD Student: Anél Wiese GCM Collaborator: Dr. Slavi Stoyanov Post-doctoral Researcher: Dr. Caroline Kilty

The Team

Background & Context The quality of CLE is important because: Learners perform better in supportive environments Report greater levels of satisfaction Are more likely to develop a humanistic orientation within them Supportive CLE can contribute to better patient care There is evidence that medical trainees are dissatisfied with their CLE, both in Ireland & internationally: Historical dissatisfaction with long hours Excessive administrative tasks Inadequate educational opportunities So, why were we interested in looking at clinical learning environments for postgraduate trainees?

Study aims This study aimed to address “What are the perspectives of stakeholders on current clinical learning environments & opportunities for improvement?” Group Concept Mapping approach- To develop a consensus amongst stakeholders on the important domains within the clinical learning environment To identify the main barriers & facilitators within these domains To identify their relative importance, & ease with which to address

Methodology GCM is an integrative mixed method approach to identify an expert group’s understanding about a topic. We used a web-based tool- Concept System Global. The procedure consists of five phases.

Phase 1- Idea generation Purposively recruited 55 participants; Consultants Trainees at all levels Nursing & Allied healthcare professionals Patient representatives Health service managers Participants completed the following focus prompt: ‘One specific barrier or facilitator to trainee doctors learning within the clinical environment is...’.

Idea generation 206 statements were generated. 97 unique ideas remained following a pruning process. Example of a statement: “A barrier to learning is where teaching is not seen as relevant to the day to day job.”

Phase 2 & 3- Sorting & Rating Sorting: A smaller representative cohort (n= 27) was then asked to sort each idea/statement into categories based on similarity in meaning- into similar or related categories, or clusters. Rating: Each participant was asked to rate each statement on the following two values: Importance to address Ease of addressing

Phase 4 & 5- Analysis & interpretation The analysis involved multidimensional scaling (MDS) & hierarchical cluster analysis. Multidimensional scaling (MDS) provides a visual representation of the similarities or distances among a set of items. MDS mapped statements into clusters based on how participants had grouped them- Generates a point map/cluster map- a visual representation of a pattern of proximities Mean rating scores for importance/ease to address were calculated. Hierarchical cluster analysis- this was an interpretative process undertaken by the research team.

Results: Phase 4 & 5- Analysis & interpretation A 10 cluster solution was identified as most representative of the results, displaying 10 discreet themes; Organisation & conditions of work - relating to the tension between providing service in busy environments, & unprotected time to learn. Time to learn with Senior doctors during patient care – relating to the way that high volume clinical workload & reduced working hours limit opportunities for training. Management & facilities – relating to the way in which hospital management values and facilitates training and the provision of facilities to support training at hospitals. Workplace culture – referring to the way in which learning and trainees are valued in the workplace. Trainer skill & support – referring to who does the training & how they are supported.

Results Interaction & feedback in clinical teams – Relating to the interpersonal relationships within the trainee’s working environment. Content, assessment & continuity of training -Referring to modalities of assessment of trainee performance and communication between trainers/ consultants as trainees progress from one post to the next Motivation & morale – Referring to morale within a struggling healthcare system, & its impact on the motivation/attitude of learners & other staff. Trainee support – Referring to reception into team, collegiality, respect and support to work within scope of practice and to challenge constructively. The role of patients in doctor’s learning – referring to patient expectations of care, willingness & provision of feedback.

Cluster Map Organisation and conditions of work 3 Cluster Map 2 1 8 9 4 10 Organisation and conditions of work Time to learn with senior doctors during patient care Management and facilities Workplace culture Trainer skill and support Interaction and feedback in clinical teams Content, assessment and continuity of training Motivation and morale Trainee support The role of patients in doctors learning 5 6 7

Rating results: Importance High degree of consensus achieved across stakeholder groups 1. Trainee Support “An atmosphere of collegiality and mutual respect between clinical staff”. 2. Time to learn with Senior doctors during patient care “ The EWTD is a barrier to trainees learning because they spend far less time in the clinical environment than previously. They miss learning opportunities arising in day to day practice because they are post call or working shifts”. 3. Interaction & feedback in clinical teams “Gaining good regular feedback on their performance by those in the immediate clinical environment is a facilitator to learning”.

Rating results: Ease to address 1. Assessment & continuity of training “Lack of clarity about the performance of the trainee in previous rotations meaning it takes quite a while to become familiar with their performance/capability”. 2. Trainer skill & support “The absence of a proper curriculum”. 3. Role of patients in doctors’ training “Patient feedback to the young doctor is beneficial and should be encouraged, especially in how they have interacted with the patient”.

Pattern Match – Importance/Difficulty

Rating- Individual Statements Ratings for individual statements identified some very specific areas which participants viewed both important & relatively easy to address. Gaining good regular feedback on their performance by those in the immediate clinical environment is a facilitator to learning Protected time being allocated to both trainers and trainees to facilitate tutorials There is no administrative support for delivering training programmes on hospital sites

Conclusion Study is one of 3 studies currently being undertaken with the overarching objective of designing guidelines for optimal learning environments Identified key domains of the learning environment Gained the perspectives of stakeholders on how important these domains are, and how easy each may be to address Strong level of consensus achieved on specific areas which participants viewed both important & relatively easy to address, i.e., Trainee support Feedback –> Single most important statement & amongst the easiest to implement.

Thank you for listening Further project details available on the RCPI website: https://www.rcpi.ie/research