1. Optimising the Clinical Learning Environment
Prof Peter W Johnston
Depute Postgraduate Dean
Scotland Deanery, North Region
NACT London January 2017

2. What is this workshop about?
Discuss education in the workplace
Understand the CLE and why it is important
The tensions that can impact on the CLE (research from ARI)
Sharing experience of attempts to improve learning environments
Explore other potential methods for optimising CLEs
Discuss and generate possible actions/goals that could improve your own CLEs.

3. How we do this
13.10 Introduction Pressures & tensions - discussion in groups Feedback Research from ARI Potential solutions – discussion in groups Feedback Optimising your own learning environment – final thoughts Close

4. Clinical Learning Environment (CLE)
The CLE is the sum of the internal and external circumstances and influences surrounding and affecting a person's learning and working:
Physical surroundings
Systems and structures
Organisational culture (e.g. relationships between staff, patients and students/trainees; shared values, norms and behaviours)
Attitudes, norms “how we do things here”
The learner – how s/he perceives the climate, interacts with the environment and its opportunities
Note that I mentioned the culture, What I mean by this is…

5. Definition Educational culture
relates to systems values and common expectations of behaviours within an organisation1
Educational climate
relates to individuals’ own perception of the environment with regard to education1
1. James LR, Choi CC, Chia-Heui EK, McNeil PK, Minton MK, Wright MA, Kim K. Organizational and psychologic climate: a review of theory and research. Europ J Work and Organisational Psychol, 2008;17:5-32
So if that’s our general definition, what about in the clinical setting? Is this different?

6. Learning or Working Environment?
The clinical learning environment = the clinical working environment
Majority of learning occurs within the workplace environment
Not traditional educational classroom setting, most occurs within the workplace. That the CLE is the CWE can create tensions and paradoxes e.g. between service and training.

7. Why look at the CLE now?
Not much action from a lot of words.

8. Why look at the CLE now?
So we now have a mandate for understanding our CLE so as to improve it?

9. Task 1 Pressures & Tensions in the CLE
Having a learning environment within a working environment can create tensions, pressures and difficulties.
In groups:
Consider the pressures and tensions in your own learning environments
Do this quickly e.g. just five minutes to discuss and 5 minutes for feedback and move onto ARI research
What pressures are the same?
What pressures are different?

10. Pressures & Tensions in the CLE – Feedback (1)
You’re not alone!
Feedback – so from the discussions can tell that there are common pressures/tensions across CLEs. What are these?

11. Pressures & Tensions in the CLE – Research (Roberts R, Cleland JA, Kitto S, Johnston PW)
Examined CLE within 2 departments within ARI to understand the factors that impact - the aim of supporting staff to direct improvements
Conducted 25 interviews with learners, trainers and management
Overarching tensions/themes:
Service and training
Workload
Interpersonal relationships
Sense of belonging & feeling valued
Disparity between staff and management (trusting; responsibility?)
Who runs the service and training (departments or the hospital?)
Seniors’ attitudes and behaviours (influential in CLE)
Willingness to learn and change versus the status quo
Does any of this sound familiar?

12. Task 2 How have you done to improve your CLE?
In groups share experiences of initiatives to improve CLE:
What was the problem?
What did you do?
Did the situation change i.e. did it work? If so, what evidence do you have?
Discuss in groups for 10 minutes and give 15 minutes for feedback and discussion. Write on flipchart what people have been doing. Ask them about the problem, the action and the consequences. Finish with – have these initiatives always been successful and how do you know that they have?

13. What worked?
(e.g. Student/staff involvement, attitude or behaviour changes, type of approach – systems?, inductions/seminars/ward-rounds?, measured/follow-up?)
Discuss in groups for 10 minutes and give 15 minutes for table feedback and discussion. Write on flipchart what people have been doing. Ask them about the problem, the action and the consequences. Finish with – have these initiatives always been successful and how do you know that they have?

14. Optimising the CLE
Complex situations require complex, multi-faceted solutions
Not just system factors and people factors but how these interact
Acknowledge the complexity of the situation (e.g. Weick’s HRO “need reluctance to simplify interpretations”)
Address and attempt to actively balance the tensions
requires embracing and openly discussing the competing demands (of service and training)
Initiate a cycle of change and seeking a position that accommodate opposing tensions
Try to better understand your own CLE – actively seek feedback from many different people
Use survey tools e.g. the UCEEM (Strand et al. for a copy)
Safe and open discussion of the problem(s)
Empower individuals to take responsibility and own the problem

15. Optimising the CLE Practical points
Foster a sense of belonging by making the students and trainees feel welcome in all areas of the department
Ensure the unit/supervisors are prepared and expecting student entry
Ensure supervisors are available for formal and informal feedback
Do the students and trainees work together and support each other?
Consider benchmarking the quality of the CLE

16. Optimising YOUR learning environment
Write down:
What improvement would you like to see (by when?)
Two actions to be taken within 6 months
Two actions to be taken by the end of the month
Two actions when you return to your desk on Monday

17. Thank you for coming, final questions?
Prof Peter Johnson Dr Ruby Roberts

18. A number of high profile sources, including the GMC standards for training in medical education and National Training Survey (NTS) returns, as well as more local reports such as the Health Improvement Scotland (HIS) review of Aberdeen Royal Infirmary, highlight the need to constantly review the quality of Clinical Learning Environments (CLEs) across specialties and localities. This is relevant to all those involved in medical education, training and healthcare delivery as an optimised CLE has the potential to cultivate learner capabilities, professionalism, well-being and enthusiasm for the practice of medicine.
Drawing on local work funded by NHS Grampian and the Scottish Medical Education research Consortium (SMERC), this workshop will initially provide an overview of what we mean by the CLE, why it is relevant to medical education and training, and what factors/tensions can impact on a CLE. We will then move to considering how best to optimise the CLE in real-life settings.
The aims of the workshop are:
to give the participants an understanding of the CLE and the tensions that can impact on it;
to share experiences of initiatives to improve CLEs;
to explore other potential methods for optimising CLEs;
to discuss and generate possible actions/goals that could improve their own CLEs.