Medical Students' Perceptions of Clinical Learning Environments in Public and Private Hospitals in Jeddah: A Mixed-Methods Study.

Background: Effective learning should be based on an understanding of how students learn. Students who are well adjusted will be actively involved in learning. The role of motivation will encourage individuals to have appropriate strategies to guide their learning, to depthly process the information which in turn produces better learning achievement. Environment creates a learning atmosphere that influences students learning motivation. This study was aimed to find out the correlation between students’ perception of clinical learning environment and learning motivation. Method: The study used quantitative method with cross sectional approach. 70 Ners students of Aisyiyah University of Yogyakarta academic year 2015/2016 answered the Clinical Learning Environment and Supervision (CLES) and Motivated Strategies for Learning Questionnaire (MSLQ) questionaires. Pearson test was used to analyze the data.Results: Most of the students (77.1%) showed positive perception about the clinical learning environment. They were more likely to be motivated extrinsically than intrinsically.The highest value of task value motivation subscales shows a mean value of 5.79 (SD = + 0.67) while the lowest value in the anxiety test sub-scale shows a mean of 3.52 (SD = + 1.23). The clinical learning environment of the head of the room leadership style sub-scale has a weak positive correlation with the motivation to learn (r = 0.297 and p = 0.012).Conclusion: There is a weak positive correlation between students’ perception of clinical learning environment and learning motivation. Clinical learning environment needs to be well prepared to meet the needs and improve students learning motivation.

IntroductionBurnout in medical students is extensive and a critical issue. It is associated with increased rates of depression, suicide, and poor perception of the educational environment. Enhancing resilience, the ability to adapt well in the face of adversity, is a potential tool to mitigate burnout and improve medical student wellness.MethodsOur resilience curriculum consisted of facilitated workshops to cultivate resilience in medical students during their core clerkship rotations. This curriculum served as an introduction to the concept of resilience and taught skills to cultivate resilience and promote wellness. The sessions allowed for identification of and reflection on stressors in the clinical learning environment, including straining team dynamics, disappointment, and uncertainty. Educational sessions included resilience skill-building exercises for managing expectations, letting go of negative emotions, dealing with setbacks, and finding meaning in daily work. Associated materials included lesson plans for small-group facilitators, learner pre- and postcurriculum surveys, and a social media activity guide.ResultsThis curriculum was delivered to 144 clerkship students at two academic institutions over the 2017–2018 academic year. Sessions were well received by medical students, with the majority of students stating that the sessions should continue. The majority of attendees found the sessions valuable and learned new ways to approach challenges.DiscussionStudents valued connecting with peers and feeling less alone through their participation. A challenge was constructing a setting conducive to comfortable reflection for all learners. Not all students found these sessions necessary. Sessions may have improved resilience levels.

BackgroundBelonging is critical for the development and wellbeing of medical students. Belonging, particularly within a ‘relational being’ paradigm, presents a significant challenge for students, especially within clinical learning environments. Co-creation is a learning relationship in which students are actively involved in the education process. It is inherently relational and promotes belonging within higher education environments. Little is known about utilising co-creation in the curriculum, within medical education. The aim of this study was to explore medical students’ experience of co-creation of learning resources within the clinical learning environment.MethodsFollowing ethical approval, medical students were invited to become co-creators of a learning bulletin resource, within the paediatric acute receiving unit, at a paediatric teaching hospital. Interpretative phenomenological analysis (IPA) was used to enable an in-depth exploration of how medical students experienced co-creation within the clinical learning environment. Medical students participated in semi-structured interviews about their experience, which were transcribed verbatim and analysed using IPA. The analysis integrated individual lived experiences into an analytic summary.ResultsNine medical students participated. Three group experiential themes were identified: identity maturation; learning community and workplace integration. The support found within this co-created learning community, along with maturation of their identity, allowed the participants to experience a challenge to their existing worldview. This shift in perspective resulted in them responding and behaving in the workplace in new ways, which enabled them to belong as themselves in the clinical learning environment. These findings were situated within the developmental concept of self-authorship, as well as contributing to a new understanding of how co-creation promoted social integration.ConclusionsCo-creation enabled students to learn in a meaningful way. The relational power of co-creation, can be harnessed to deliver participatory learning experiences, within our increasingly complex healthcare environment, to support the learning, development and integration of doctors of the future.

Background: The human papillomavirus, or HPV, is a serious worldwide public health issue since it has been connected to illnesses including cervical cancer. Although there are effective HPV vaccines available, medical students' lack of knowledge may make it more difficult for them to encourage vaccination and lower the risks of HPV-related illnesses. Objective: This study aimed to assess the knowledge of HPV vaccination among medical students, identifying key areas of strength and weakness to inform targeted educational interventions. Methodology: A cross-sectional study was conducted from January to June 2023 at People’s University of Medical and Health Sciences for Women (PUMHSW), Nawabshah, Pakistan, involving 420 medical students. A standardized, self-administered questionnaire was used to gather data, and SPSS was used for analysis. Descriptive statistics and chi-square tests were used to look at relationships between knowledge levels and demographic characteristics. Results: The survey found that although most people (90%) were aware of HPV's role in cancer and the advantages of vaccination (82.38%), fewer people (80.95%) were aware of the safety of vaccines. Age, academic year, and knowledge levels were shown to be significantly correlated; and older students (88.89%, p = 0.01) showed better knowledge. Compared to students in higher academic years, those in lower academic years, especially those in their first year (93.33%, p = 0.01), exhibited noticeably lower knowledge levels. Conclusion: While medical students possess strong awareness of HPV and vaccination benefits, gaps in knowledge regarding vaccine safety persist. Addressing these gaps through targeted educational interventions is essential to enhance HPV vaccination advocacy and public health outcomes.

A Survey on Turkish nursing students' perception of clinical learning environment and its association with academic motivation and clinical decision making

Objectives: This study aimed to investigate the perceptions of International Islamic University Malaysia (IIUM) Kuantan nursing students, clinical nurse instructors, and staff nurses of the support offered to student nurses during learning in a clinical setting. Methodology: A cross-sectional study was carried out on undergraduate nursing students (n=118), and clinical instructors (n=8) at the faculty or Kulliyyah of Nursing, IIUM, using the Clinical Learning Environment, Supervision and Nurse Teacher (CLES-T) survey. Descriptive analysis was used to investigate the sociodemographic data, and further statistical tests were conducted with regard to their levels of perception. Results: Overall, the participants perceived the clinical learning environment to be good. There was no difference in perception between nursing students and the clinical nurse instructors (p>0.05). There was no significant difference in terms of gender and levels of perception (p>0.05). This study did find a significant relationship between level of study and area of posting for students and perception levels (p<0.05). Conclusion: This study showed that the majority of the students had positive perceptions of the clinical learning environment, supervision, and nurse teachers. The school provided sufficient support within the clinical learning environment in term of supervision and nurse teachers. These results will help the nursing school in terms of upgrading the clinical learning environment and encouraging collaboration with hospital management to provide a good clinical learning experience for students.

Healthcare-seeking behavior plays a crucial role in early diagnosis and effective treatment. In conflict-affected low-income communities like Sudan, factors affecting healthcare-seeking behavior and the rationale for engaging in self-medication practices can vary tremendously in comparison to stable communities. Responsibilities placed upon medical students who faced displacement are substantial within their host communities. This study aims to explore the role of armed conflict and the displacement crisis in reshaping the factors affecting the healthcare-seeking behavior and self-medication practices of medical students in Sudan. A Quantitative cross-sectional study was conducted targeting displaced medical students enrolled in different public and private universities across Sudan. Data were collected using structured questionnaires that assessed participant’s social data, health awareness and help-seeking behavior, preference for health facilities and self-diagnosing and self-medication practices. Among the 2410 participants, most were females (64%) and over 21 year old (72.4%), 66.7% understood health as multidimensional, yet only 12.1% prioritize social well-being. Self-medication practices was reported by 36.6% of participants, particularly with antibiotics, vitamins and NSAIDS. Older students ≥21, males and those in advanced academic years were more likely to practice self-diagnosing and self-medication. Higher academic years (odds ratio [OR] for fourth year = 1.94) and Urban residency (OR = 1.28) were more associated with positive health attitudes. Private university students were less likely to seek care from their own college hospitals (OR = 0.78). Repeated displacement was linked to poorer attitudes toward health realization (OR = 0.62) and reduced trust in their own health facilities (OR = 0.58). The study showed low awareness of mental and social health and a high prevalence of self-medication among Sudanese medical students, especially analgesics and vitamins. Health education campaigns and empowerment of health infrastructure can help to improve access to healthcare services.

Research on dental students' perceptions of clinical learning environments is needed to identify strengths, weaknesses, and need for interventions to sustain high-quality dental education, but a primary challenge has been the absence of an instrument designed to assess these perceptions. The Dental Clinical Learning Environment Instrument (DECLEI) is a new instrument developed specifically for dental clinical learning environments according to psychometric standards and validated in Europe. The aim of this study was to perform a preliminary validation of DECLEI in a U.S. dental school, thus providing data for subsequent validation in a larger, multi-institution sample. After five experienced faculty members assessed DECLEI's item relevance and content validity, the instrument was distributed in 2016 to 144 third- and fourth-year dental students at the University of Iowa College of Dentistry & Dental Clinics. All 144 questionnaires were completed (100% response rate). The results were tabulated and submitted to principal component analysis with an orthogonal rotation to assess internal structure of the measure. Internal consistency reliability was assessed using Cronbach's alpha coefficient and corrected item-total correlations. The results showed that, of the initial 24 items, principal component analysis allowed 18 items grouped in five domains: student-faculty interaction, equipment and patient issues, didactic-clinical components interaction, negative perceptions, and self-assessment. The Cronbach's alpha coefficients for these five domains ranged from 0.52 to 0.80. These results suggest that DECLEI has the potential for use as a reliable instrument to assess students' perceptions of clinical learning environments at U.S. dental schools, thus supporting the need for a definitive validation analysis in a larger sample.

Introduction: The clinical learning environment (CLE) is an interactive network of forces within the clinical setting, i.e., staff, the patient, the preceptor, and the nurse educator, that influence the clinical learning outcomes and have impact on student behaviours. Hence, clinical experiences are important for student learning and professional development. Nursing as a profession has evolved in response to society's needs for well-prepared, caring practitioners during clients’ episodes of illness and promote health among all age groups. Clinical education is an essential part of nursing education. It provides students with the opportunity to put the knowledge, skills and concepts they acquire from classes into practice Experience gained in clinical learning environments makes a major contribution to students' professional development by enabling them to think in new ways. The aim of the study is to assess the perception of clinical learning environment among the students in selected nursing colleges. Method: Quantitative, descriptive cross-sectional design was used to evaluate the nursing students' perceptions at college of nursing, sir J J Hospital, Mumbai by using structured questionnaires. Probability simple random lottery method used to select 200 nursing students. Descriptive analysis done with frequency and percentages and fisher exact test used to find out association between between the perception of clinical learning environment among the students with their selected demographic variables. Result: In this study, 88(44%) nursing students were in 21-22 year of age group and majority 106(53%) of the participants were female. 31%Nursing student were studying in third year while 69(34.5%) had clinical experiences 536 to 1702 hours. Perception of clinical environment among nursing students was good 109(54.5%) where 86(43%) having excellent. Discussion: The study showed association between selected demographic year of nursing degree, type of supervision with the perception of clinical learning environment among the students. The nursing students were oriented to unit settings/ wards by clinical instructor/teacher, they felt that they receive individualized supervision and continuous feedback, round clock supervision frequent visit and suggestions of improvement from clinical instructors.

Given the rigors of medical training with its high documented prevalence of mental issues as well as the global need to safeguard the well-being of medical students, there is an urgency to assess the well-being of medical students and their perception of support from their respective medical schools during their education. This also applies in the context of public medical school students in the Philippines, where there is still a relative lack of literature. This cross-sectional study investigates the well-being and such perceptions of medical students at the University of the Philippines College of Medicine (UPCM). The study uses a quantitative approach using a subset of secondary data from a college-wide survey online that was disseminated, through convenience sampling, to medical students from October 3, 2018 to December 3, 2018. A total of 432 responses were included in the analysis, out of the total student population of the included learning unit levels of 809. Participants were grouped based on their entry into medical school, either through the Integrated Liberal Arts and Medicine (INTARMED) program or lateral entry. Exclusion criteria comprised responses from Learning Unit I-II (pre-medical proper) students and incomplete survey sets. Responses were interpreted using established scales such as the World Health Organization Well-Being Index (WHO-5), Perceived Stress Scale-4 (PSS-4), and Oldenburg Burnout Inventory-Medical Student (OLBI-MS). Data analysis involved statistical techniques including one-way ANOVA and independent samples t-test using Statistical Package for the Social Sciences (SPSS). The findings suggest that medical students at UPCM generally find the administrative and academic systems satisfactory, but express concerns about inadequate educational resources and infrastructure, especially as they progress through their studies and engage more with clinical settings like the Philippine General Hospital (PGH). As students advance through the program, there are different patterns for wellbeing outcomes, including decreasing perceived stress and increasing burnout. In particular, LU IV and LU VII students reported lower well-being and higher burnout levels, respectively. This is potentially due to heavier workloads and clinical responsibilities. Lateral entrants, who are older and typically enter with prior degrees, tend to have higher well-being and lower burnout compared to INTARMED students, suggesting age and previous educational experience may play a role in adjustment and coping mechanisms. Overall, the study highlights the medical students' generally satisfactory perception of medical educational aspects, as well as the patterns of wellbeing throughout their medical college experience. Furthermore, it identifies different areas for improvement to ensure effective education and student mental health. By analyzing trends across different year levels, the study provides insights for interventions and program refinements, while also suggesting avenues for further research to assess student experiences over time.

Improvements in the clinical learning environments of a health-based training institution depend on identification of gaps. There was need to conduct studies around clinical learning environments in Sub-Saharan Africa since they were rated low and because there were concerns on the adequacy and quality of healthcare services that were available. This study was anchored on the constructivist theory with underlying pragmatic approaches, the main objective being to examine the perception of clinical learning environment among undergraduate health-based students at Masinde Muliro University of Science and Technology (MMUST). Cross-sectional study design employing mixed methods was used. The population of the study included all second, third, and fourth-year students who were enrolled in the study during a period spanning from June 2024 to November 2024. Stratified random sampling technique was used to arrive at a sample size of 302 participants computed through Taro Yamane formula and purposive sampling used for the interviews with students’ class representatives. Data was respectively collected by use of interview schedule and self-administered questionnaire; analyzed thematically, and through descriptive-inferential statistics using SPSS version 27, P<0.05. The questionnaire was found to be reliable with Cronbach’s alpha coefficient of 0.830. The study realized a response rate of 90%. Majority (59.9%, n=272) of the participants were male, and persons aged between 18-23 years (87.9%), mean age of 21 years. Significant mean differences were realized on the bases of level of study and type of academic program. The overall clinical learning environment was found to be very good with a score of 84% (n=200), whereas perceptions on clinical teaching was at 86.29% (n=100). However, the psycho-social support system domiciled in the clinical teaching was rated low with a mean of 2.8(SD=0.23). Themes that emerged during the interviews were status, challenges, and proposed solutions to challenges of the clinical learning environment. It was concluded that the clinical learning/teaching environment was positively perceived by students despite having a psycho-social support system that was rated low. Recommendations were made on the need for strengthening the environment’s psycho-social support system, and further series of research involving teachers.

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work. </p><p dir="ltr"><br></p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr"><br></p><p dir="ltr">Results<br>In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr"><br></p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4<br></a><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work. </p><p dir="ltr"><br></p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr"><br></p><p dir="ltr">Results<br>In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr"><br></p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4<br></a><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>

<p dir="ltr">Background<br>Clinical practice is an important part of medical education, providing students with an opportunity to put theory into practice and develop clinical skills. Primary health care (PHC) has gained increasing importance for students' development of clinical skills and provides a place where students can prepare for their future profession under supervision. The clinical learning environment in PHC is also a workplace with patients, supervisors, and other professionals, which creates a complex learning environment. In PHC, students meet authentic patients as they come to PHC with they problems when the students participate in everyday clinical work.</p><p dir="ltr">In order to ensure the quality of the learning environment in PHC and provide an opportunity for both the PHC centre and the university to receive up-to-date feedback, it is important that the students have access to an evaluation instrument. The instrument needs to measure several aspects of the learning environment.</p><p dir="ltr">To ensure quality and the student's opportunity to progress in their journey towards a future profession, it is important to gain an understanding of how the clinical learning in PHC is perceived by students and patients and how it can be evaluated.</p><p dir="ltr">Aims<br>The aim of Study I was to adapt and validate the Clinical Learning Environment and Supervision (CLES) instrument to measure medical students' perceptions of their learning environment in PHC. In Study II, the aim was to explore medical students' perceptions of the clinical learning environment in PHC and how these perceptions vary according to the stage in the education programme. In Study III, the aim was to explore the perceptions of ordinary patients in PHC when participating in encounters with medical students and what they believe they contribute to the students' learning. In Study IV, the aim was to explore medical students' perceptions of learning from patient encounters in a PHC context.</p><p dir="ltr"><br></p><p dir="ltr">Methods<br>In Study I, the CLES instrument was adapted to measure medical students' learning environment in PHC. The CLES instrument, which contains 25 items, was sent electronically to 1,256 students in the medical programme over 9 semesters. The study used exploratory factor analysis based on the principal components method, followed by oblique rotation, to confirm the adequate number of factors in the data. Construct validity was assessed by factor analysis. Confirmatory factor analysis was used to confirm the dimensions of the CLES instrument. In Study II, content analysis was used to analyse the students' free text comments, which they wrote in connection with the usual evaluation of their learning environment. In Study II, an adapted CLES instrument was used as an evaluation instrument. Study III was a qualitative study where individual interviews were analysed by inductive content analysis. A total of 13 patients were interviewed immediately after they had met a medical student during their visit to the PHC centre. Study IV was a qualitative study that used individual interviews with a semi-structured interview guide. The data was analysed by inductive content analysis. In total, 21 medical students were interviewed.</p><p dir="ltr">Results</p><p dir="ltr">In Study I, a total 394 of students answered the questionnaire. The construct validity showed a clearly indicated four-factor model. The cumulative variance explanation was 0.65. The overall Cronbach's alpha was 0.95. The adapted CLES instrument had high construct validity and reliability and high internal consistency. In Study II, the two main themes were 'The supervisor was the central factor in determining the meaningfulness of the placement at all stages of the education' and 'Basic prerequisites for perceived clinical learning were to having an active role in an authentic clinical context and being trusted to work independently with patients'. The three categories were 'The perceived relationship with the supervisor', 'The perceived journey to become a doctor' and 'The perceived structure and culture'. In Study III, one main theme was found: 'Participating in a dialogue adapted to students' needs without being aware of one's role as a teacher' and four categories: 'Expectations and conditions for participation', 'Contribution to learning', 'Collaboration in learning', and 'Perceived benefit for the patient'. In Study IV, the main theme was 'The individual patient encounters are the key to learning in PHC'. Four categories were found: 'Patient encounters in primary health care are instructive, rewarding, and challenging', 'Encounters with patients in PHC provide opportunities for gradual professional development', 'A committed supervisor plays a significant role in learning', and 'Learning in PHC and learning in hospitals complement one another'.</p><p dir="ltr">Conclusion<br>The CLES evaluation instrument was adopted for medical students and was subsequently seen as a useful tool for their evaluation of the clinical learning environment in PHC. Students' perceptions and experiences of clinical practice in PHC showed that the supervisor and patient were important for the student's progression. Active participation in clinical work and patient encounters, and the mix of patients in PHC, were seen as important for the development of clinical and communication skills. Patients were not always aware of their role in the student's learning but were able to contribute in many ways. The patients adapted to the students and allowed the students to perform examinations at their own pace. Students felt responsible for the patient and sometimes felt uncertain about whether they had the necessary competence. Committed supervisors provided students with the confidence to act on their own, and the students were aware of their own development.</p><h3>List of scientific papers</h3><p dir="ltr">I. <b>Öhman E,</b> Alinaghizadeh H, Kaila P, Hult H, Nilsson G.H, Salminen H. Adaptation and validation of the instrument Clinical Learning Environment and Supervision for medical students in primary health care. BMC Medical Education. 2016. 16:308. <a href="https://doi.org/10.1186/s12909-016-0809-8">https://doi.org/10.1186/s12909-016-0809-8</a></p><p dir="ltr">II. Salminen H, <b>Öhman E,</b> Stenfors-Hayes T. Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study. BMC Medical Education. 2016. 16:313. <a href="https://doi.org/10.1186/s12909-016-0837-4">https://doi.org/10.1186/s12909-016-0837-4</a></p><p dir="ltr"><br>III. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. How patients in primary health care perceive their contribution to medical students' learning - an interview study. [Manuskript]</p><p dir="ltr"><br></p><p dir="ltr">IV. <b>Öhman E,</b> Toth-Pal E, Hult H, Nilsson G.H, Salminen H. Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study. BMC Medical Education. 2023. 23:935. <a href="https://doi.org/10.1186/s12909-023-04923-9" rel="noreferrer" target="_blank">https://doi.org/10.1186/s12909-023-04923-9</a></p>

Internet Addiction (IA) has become a significant public health issue, particularly among medical students. However, research on IA within medical students with a psychiatric major, who receive specialized mental health training, remains limited. This study aimed to examine the prevalence of IA and its associations with mental health variables (depression, anxiety, impulsivity) and social factors among medical students with a psychiatric major, while exploring the mediating role of mental health variables in the relationship between academic year and IA. A cross-sectional survey was conducted with 390 medical students with a psychiatric major at Chongqing Medical University from February to May 2021. Participants completed validated instruments, including Young's Internet Addiction Test (Y-IAT), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Barratt Impulsiveness Scale (BIS-11). Demographic and social factors were analyzed using Mann-Whitney U tests, chi-square test, correlation analyses. Mediation analyses were conducted using the SPSS PROCESS macro (Model 4). The average Y-IAT score was 37.57 ± 13.80, with 17.7% meeting the criteria for IA (Y-IAT ≥50). Additionally, participants reported low levels of depressive (PHQ-9 = 2.04 ± 3.01) and anxiety symptoms (GAD-7 = 1.26 ± 2.58). IA was significantly associated with increased impulsivity (r = 0.534, p < 0.001), depression (r = 0.399, p < 0.001), anxiety (r = 0.347, p < 0.001), academic stress (r = 0.239, p < 0.001), poor peer relationships (r = 0.199, p < 0.001), and peer bullying experiences (r = 0.137, p < 0.05). A higher academic year was associated with a reduction in IA, partly mediated by decreased impulsivity (B = -0.7556, 36.60%) and depressive symptoms (B = -0.2640, 12.80%). Medical students with a psychiatric major showed a relatively lower prevalence of IA, depressive and anxiety symptoms. Higher academic years were associated with reduced IA via lower impulsivity and depressive symptoms, potentially due to enhanced psychological literacy. Additionally, poor peer and parental relationships, along with experiences of peer bullying, were linked to higher IA risk, highlighting the importance of stronger social support and early intervention. Future studies should explore targeted psychological and educational interventions to mitigate IA among students.