Clinical Learning Environment Research Articles

Girls in scrubs: An ethnographic exploration of the clinical learning environment.

Gender bias is an enduring issue in the medical profession despite women being more represented within medical schools and the health care workforce in numerous countries across the world. There have been frequent calls for further exploration of gender-based discriminations within medical education, owing to its lasting impact on student's professional development and career trajectories. This paper presents an ethnographic exploration of the experiences of female medical students and doctors in the clinical learning environment (CLE), aiming to disrupt the cycle of gender inequity in the clinical workplace. Our research field involved two teaching wards in a Scottish urban hospital, where 120 h of non-participant observations were conducted over 10months. Combining purposive and convenience sampling, we conducted 36 individual interviews with key informants, which included medical students, foundation doctors, postgraduate trainees, consultant supervisors, and other health care professionals such as nurses and pharmacists. Data was thematically analysed using Bourdieu's theory of social power reproduction. The research team brought diverse professional backgrounds and perspectives to the exploration of data on gendered encounters. Combining the observational and interview data, five themes were generated, which suggested gender-related differentials in social and cultural capital that the participants acquired in the CLE. Experiences of discriminatory behaviour and stereotypical thought processes impacted the female students' engagement and drive towards learning, implying an adverse influence on habitus. In contrast, the valuable influence of gendered role-models in building confidence and self-efficacy signified a positive transformation of habitus. The research participants displayed considerable internalisation of the gendered processes in the CLE that appeared to be linked to the transient nature of clinical placements. This research reveals that despite constituting the majority demographic of medical school, female students struggle to gain social and cultural capital. Gendered hierarchies that structure clinical workplaces disadvantage female students and doctors, and the differential experiences transform their habitus. Based on our theoretically informed investigation, we advocate for role-models given their positive impact on students' and doctors' habitus. Additionally, medical educators may consider extended clinical placements that provide opportunities for female students and early-career doctors to secure social and cultural capital through integrating better in health care teams and building meaningful interprofessional relationships.

Effects of a Novel Blended Virtual Reality and Clinical Learning Environment on the Learning Transfer of Anesthesiology Residents

The use of educational technology is considered a necessity due to the increasing changes in medical education. This study aimed to design a novel blended virtual reality and clinical learning environment (CLE) and to investigate its effectiveness in the learning transfer of anesthesiology residents during spinal anesthesia procedures. In this experimental study, 25 residents (academic year 2020/2021) were randomly divided into blended (n=11) and clinical (n=14) groups. Spinal anesthesia training for the blended group was performed in the virtual training laboratory (week 1) and the operating room (from week 2 to week 4), while for the CLE group, it was only performed in the operating room. Training, based on task-centered learning, was provided for both groups, and then, a 360-degree assessment of learning transfer was conducted by professors, patients, co-workers, and self-assessments using a standard questionnaire. Data were analyzed using non-parametric tests. There was a significant difference in the learning transfer of residents between the blended and CLE groups (U=39, P=0.03<0.05). There was also a significant difference in the subcategories of learning transfer according to the professors and co-workers; however, there was no significant difference according to the patients and self-assessments. The blended VR/CLE learning environment was more effective than CLE in improving residents’ learning transfer. Besides, an increase in scores indicated an improvement in professional competence.

The implementation of CLES+T questionnaire in the Italian nursing bachelor’s degree program for the evaluation of clinical learning environment by nursing students: a study protocol

BACKGROUND: The practical training process represents a crucial step in the university process for students on degree courses in the health and medical professions. This discussion is emphasized for nursing students, who, for each stage of the internship, may have the opportunity to enrich themselves in practical terms and to be able to compare themselves with the reality of work physically. Based on this discussion, it is essential to carry out a periodic evaluation of the working realities. OBJECTIVES: The main objective of this work is to implement an evaluation tool for the clinical training environment to ensure feedback for both the healthcare facility under consideration and to improve the quality of university clinical training. METHOD:    This research study protocol envisages an observational study as the type of study, with recruitment of nursing degree courses to subsequently include students from the various academic years. The study involves the application of the CLES+T questionnaire in participating degree courses, initially to be able to have an overall vision and subsequently to be able to implement it as a permanent evaluation tool. EXPECTED RESULTS: It is expected, from the study described in this protocol, that the participating population will consider the questionnaire as a way of critically analysing the clinical environment. A broad participation of the nursing student population and good feedback of the examined environments is expected.

Assessment of Factors Associated With the Acquisition of Competencies among Undergraduate Nursing Students in Ugandan Universities

Purpose: Like other developing countries, Uganda grapples with the critical challenge of equipping nursing students with essential clinical competencies. These competencies encompass vital nursing skills, knowledge, attitudes, and behaviors crucial for effective nursing practice. This study assessed student perceptions and confidence in applying acquired clinical skills among undergraduate nursing students in Ugandan universities.
 Methodology: A descriptive cross-sectional study was used to assess bachelor's in nursing students from central and western Ugandan universities. Data were entered into Excel and exported to SPSS version 22. Results were presented using frequencies, pie charts, percentages, and tables. Chi-square tests were conducted to assess associations of the variables in the study.
 Findings: The study showed that acquisition of clinical competencies is positively correlated with students’ perceptions (r=0.775) (p=0.000), Institutional factors(r=0.668) (p=0.000), clinical learning environment (r=0.556) (p=0.000), clinical feedback (r=0.439) (p=0.000). The study further shows that 69.9% (n=70) had adequate clinical learning experience, while 31% (n=31) had inadequate clinical learning experience. This implies moderate student supervision, feedback, and an unfavorable clinical learning environment. Competency acquisition in student nurses is positively influenced by the active involvement of students' perceptions, institutional factors, and a supportive clinical learning environment. A sufficient amount of clinical experience is pivotal in developing competent student nurses.
 Unique Contribution to Theory, Practice and Policy: Management should always invite experienced professionals to share career experiences to enhance realistic perceptions among nursing students. Students should be given more time to practice in clinical settings, and management should advocate for including student attitude tests in orientation programs across nursing and clinical training universities.

Implementation of a Trauma-Informed Challenging Interactions Reporting Tool to Improve our Clinical Learning Environment

ProblemWorkplace mistreatment is a contributor to resident burnout; understanding and intervening against mistreatment is one key tool in mitigating burnout. While ACGME survey data alerts programs to general mistreatment trends, those data are not detailed enough to inform local interventions. Our team designed and implemented a Challenging Interactions Reporting Tool (CIRT) to characterize the experiences of our trainees at a granular level and to inform targeted interventions for improvement. ApproachOur CIRT was offered to 158 residents in August 2020 via REDCap. Residents submit electronic reports that are reviewed weekly by program leaders who develop action plans for each report. Reporters can identify themselves or can choose to remain anonymous. When “hot spots” for mistreatment are identified in our hospital, we implement a targeted systems-level intervention. OutcomesResidents filed 275 reports between August 2020 and December 2022. Reports represented all training environments and involved all interprofessional members of clinical teams. Residents reported awareness of, use of, and satisfaction with the tool. Next StepsOur program created the CIRT as a tool to inform local interventions for improving the safety of our clinical learning environment. We continue to disseminate our tool across our hospital’s GME programs and are now measuring the impact of our interventions.

Psychological safety and perceived organizational support in emergency medicine residencies.

The clinical learning environment (CLE) is a key focus of the Accreditation Council of Graduate Medical Education. It impacts knowledge acquisition and professional development. A previous single-center study evaluated the psychological safety and perceived organizational support of the CLE across different specialties. Building on this work, we explored and evaluated psychological safety and perceived organizational support across multiple heterogeneous emergency medicine (EM) residencies to identify trends and factors affecting perceptions of the CLE. Using the Psychological Safety Scale (PSS) and Survey of Perceived Organizational Support (SPOS), residents from seven U.S. EM residencies were surveyed using REDCap software from September through November 2021, with 300 potential respondents. As an adjunct to these surveys, three open-ended questions were included regarding features of their learning environments. A total of 137 out of 300 residents completed the survey. The overall response rate was 45.7%. There was a variable response rate across programs (26.0%-96.7%). Pooled results demonstrate an overall positive perception of CLEs, based on positive mean responses (i.e., "Members of my department are able to bring up problems and tough issue" had a mean of 4.2 on a 5-point Likert scale). Open responses identified teaching, collegiality, and support from program leadership as supportive features of the CLE. Confrontational interdisciplinary communication, a sense of being devalued, and off-service rotations were identified as threats or areas for improvement to the CLE. PSS and SPOS scores were generally positive in this multi-institution study, consistent with the prior single-institution study indicating that EM is often considered psychologically safe and supportive. EM training programs can consider using the PSS/SPOS to audit their own programs to identify areas for improvement and foster supportive features already in place.

Understanding resident wellness: A path analysis of the clinical learning environment at three institutions

Purpose The clinical learning environment (CLE) affects resident physician well-being. This study assessed how aspects of the learning environment affected the level of resident job stress and burnout. Materials and methods Three institutions surveyed residents assessing aspects of the CLE and well-being via anonymous survey in fall of 2020 during COVID. Psychological safety (PS) and perceived organizational support (POS) were used to capture the CLE, and the Mini-Z Scale was used to assess resident job stress and burnout. A total of 2,196 residents received a survey link; 889 responded (40% response rate). Path analysis explored both direct and indirect relationships between PS, POS, resident stress, and resident burnout. Results Both POS and PS had significant negative relationships with experiencing a great deal of job stress; the relationship between PS and stress was noticeably stronger than POS and stress (POS: B= −0.12, p=.025; PS: B= −0.37, p<.001). The relationship between stress and residents’ level of burnout was also significant (B = 0.38, p<.001). The overall model explained 25% of the variance in resident burnout. Conclusions Organizational support and psychological safety of the learning environment is associated with resident burnout. It is important for educational leaders to recognize and mitigate these factors.

Mechanisms of Near-Peer Learning in a Longitudinal Clerkship: A Grounded Theory Study.

Many medical schools incorporate longitudinal clerkships, which promote continuity and may offer early clinical exposure during the preclinical curriculum. However, the mechanisms of near-peer learning and how it contributes to the development of clinical skills in longitudinal clinical experiences are less clear. The authors explored how peer-to-peer interactions among medical students influenced their developmental trajectories from nascent clinicians to more seasoned practitioners capable of juggling dual roles of clinical care and clinical supervision within longitudinal clerkships. The Education-Centered Medical Home (ECMH) at Northwestern University Feinberg School of Medicine is a longitudinal clerkship that represents an ideal setting to explore peer learning. At ECMH continuity is established across all 4 years of medical school among small groups of students from each year, a preceptor, and a panel of outpatients. The authors conducted 6 focus groups and 9 individual interviews between March 2021 and February 2023 with medical students from all years. Using constructivist grounded theory, the authors collected and analyzed data iteratively using constant comparison to identify themes and explore their relationships. Within ECMH, peer relationships fostered an informal learning culture that enabled meaningful peer interactions while reinforcing the established culture. The authors identified 3 essential learning practices between senior and junior medical students: preparing for patient encounters, shifting roles dynamically during the joint encounter, and debriefing encounters afterwards. These practices strengthened learning relationships and supported students' developmental trajectories. Longitudinal peer learning relationships enabled meaningful peer interaction that influenced medical students' clinical development and capability for clinical supervision. Mutual trust, familiarity, and continuity facilitate targeted feedback practices and growth at the edge of junior students' capabilities. Optimizing this peer learning environment and seeking new opportunities to use longitudinal peer learning in clinical environments could promote psychological safety and professional identity formation for medical students.

Clinical experiences of RN to BScN nursing students in Kenyan universities

Introduction and objective: Clinical learning environments play a great role in nursing training as they allow nursing students to develop their clinical skills by combining cognitive, psychomotor and affective skills. Consequently, clinical learning environments enable nursing students to bridge the theory-practice gap. Fewer studies have examined the clinical experiences of RN to BScN students in Kenya. This paper is part of analytical memo of a larger PhD study that sought to explore and describe the support needs of RN to BScN students in Kenyan universities. The paper focuses on clinical experiences of RN to BScN students.Methods: Using a qualitative phenomenological approach, ten focus group discussions were conducted with 100 RN to BScN students, purposively sampled from four universities in Kenya. Data were analyzed using Tesch’s data analysis protocol. The article has adhered to Consolidated criteria for reporting qualitative studies.Results: The data on RN to BScN students’ clinical experience revealed two themes: curriculum challenges and practice environment and six sub-themes: redundant learning outcomes, redundant clinical assessments, not acknowledging prior learning, lack of clinical supervision, lack of learning resources and “an extra pair of hands”.Conclusions: The study findings highlight the need for review of clinical learning outcomes for the RN to BScN students in Kenya. The findings emphasize the need for collaborative partnerships between universities, clinical learning environments, nurse educators, and policy makers, to design of clinical learning outcomes relevant to RN to BScN students in Kenya.

The effects of clinical learning environment and career adaptability on resilience: A mediating analysis based on a survey of nursing interns.

The resilience education of intern nursing students has significant implications for the development and improvement of the nursing workforce. The clinical internship period is a critical time for enhancing resilience. To evaluate the resilience level of Chinese nursing interns and explore the effects of factors affecting resilience early in their careers, focusing on the mediating roles of career adaptability between clinical learning environment and resilience. The cross-sectional study design was adopted. From March 2022 to May 2023, 512 nursing interns in tertiary care hospitals were surveyed online with the Connor-Davidson Resilience Scale, the Clinical Learning Environment Scale for Nurse and the Career Adapt-Abilities Scale. Structural equation modelling was used to clarify the relationships among these factors. Indirect effects were tested using bootstrapped confidence intervals. The nursing interns showed a moderately high level of resilience [M (SD) = 70.15 (19.90)]. Gender, scholastic attainment, scholarship, career adaptability and clinical learning environment were influencing factors of nursing interns' resilience. Male interns with good academic performance showed higher levels of resilience. Career adaptability and clinical learning environment positively and directly affected their resilience level (β = 0.62, 0.18, respectively, p < .01). Career adaptability was also positively affected by the clinical learning environment (β = 0.36, p < .01), and mediated the effect of clinical learning environment on resilience (β = 0.22, p < .01). Clinical learning environment can positively affect the resilience level of nursing interns. Career adaptability can affect resilience directly and also play a mediating role between clinical learning environment and resilience. Thus, promotion of career adaptability and clinical teaching environment should be the potential strategies for nursing interns to improve their resilience, especially for female nursing interns with low academic performance.

Exploring the sociocultural experiences of student veterinary nurses in the clinical learning environment through the lens of situated learning theory.

Student veterinary nurses (SVNs) complete significant time in clinical placements and this training can have a positive or negative impact on the development of professional skills and identity. A cross-sectional design, using semi-structured interviews, explored 12 SVNs' experiences of clinical placements. Interpretative phenomenological analysis was used to explore each individual participant's experience, prior to the identification of themes across participants' experiences. Most students reported a sense of belonging within the practice team, which fostered engagement. Clinical supervisors were considered key role models and vital support for student progress. Students reported conflict between the demands of the practice and the requirements of their student status. Some poor interpersonal interactions led to reduced confidence. The results may not reflect experiences of the diversity of student demographics, such as those students with protected characteristics, as described in the Equality Act 2010, who may encounter specific workplace challenges. To ensure parity and positive experiences, accredited educational institutes can plan regular engagement with student feedback and support of the training practice. Training practice teams can ensure they are meeting the student's needs and fostering a positive learning environment by adhering to the RCVS Framework for Veterinary Nurse Education and Training, which will, in turn, benefit the whole team. Clinical supervisors can play a convening role in increasing belonging and participation within the clinical learning environment.

Integrating a self-directed ultrasound curriculum for the internal medicine clerkship

BackgroundIncorporating ultrasound into the clinical curriculum of undergraduate medical education has been limited by a need for faculty support. Without integration into the clinical learning environment, ultrasound skills become a stand-alone skill and may decline by the time of matriculation into residency. A less time intensive ultrasound curriculum is needed to preserve skills acquired in preclinical years. We aimed to create a self-directed ultrasound curriculum to support and assess students’ ability to acquire ultrasound images and to utilize ultrasound to inform clinical decision-making.MethodsThird year students completed the self-directed ultrasound curriculum during their required internal medicine clerkship. Students used Butterfly iQ+ portable ultrasound probes. The curriculum included online modules that focused on clinical application of ultrasound as well as image acquisition technique. Students were graded on image acquisition quality and setting, a patient write-up focused on clinical decision-making, and a multiple-choice quiz. Student feedback was gathered with an end-of-course survey. Faculty time was tracked.ResultsOne hundred and ten students participated. Students averaged 1.79 (scale 0–2; SD = 0.21) on image acquisition, 78% (SD = 15%) on the quiz, and all students passed the patient write-up. Most reported the curriculum improved their clinical reasoning (72%), learning of pathophysiology (69%), and patient care (55%). Faculty time to create the curriculum was approximately 45 h. Faculty time to grade student assignments was 38.5 h per year.ConclusionsStudents were able to demonstrate adequate image acquisition, use of ultrasound to aid in clinical decision-making, and interpretation of ultrasound pathology with no in-person faculty instruction. Additionally, students reported improved learning of pathophysiology, clinical reasoning, and rapport with patients. The self-directed curriculum required less faculty time than prior descriptions of ultrasound curricula in the clinical years and could be considered at institutions that have limited faculty support.

Enhancing sense of belonging in nursing student clinical placements to advance learning and identity development

Clinical placements are considered one of the “hallmarks” of nursing education. In these settings, students can build upon their theoretical learning by applying knowledge, practicing skills, connecting with nurses and other medical professionals, and creating opportunities to work with diverse populations. As a result, students begin to hone their nurse identity, and build confidence and self-esteem. Importantly, the development of a nursing identity through clinical placement work is improved by integrating opportunities that increase belongingness. Campus climate plays a significant role in creating the environment necessary for belongingness to flourish and leads to enhanced student learning. Taking the role of positive campus climate into consideration, this article argues that instructors supervising undergraduate nursing students in clinical learning environments must create inclusive climates for their students to increase positive educational outcomes. Specific recommendations for creating inclusive clinical learning environments are provided.

Clinical Placement Experience, Supervision, and Nursing Career Aspirations of Undergraduate Nursing Students in Sarawak, Malaysia

This study aimed to explore nursing students' perceptions of the clinical learning environment and mentorship during their clinical placement in hospitals and how these factors relate to their intention to work as a nurse upon graduation. A survey was conducted among nursing students who had completed at least 12 months of clinical practice in hospitals located in Kuching, Sarawak, between January 2022 and February 2023. Data were analysed using percentages, frequencies, mean, standard deviation, t-test, Pearson's correlation, ANOVA, and regression analysis. Our findings revealed a significant correlation between the sociodemographic characteristic such as age of students and year of study towards clinical learning experience. Student perceived ward as good learning environment, clinical teacher teaching expertise, and clinical teacher ability to integrate between knowledge and practice rated the most satisfying element in students’ clinical experience. Our study established a significant correlation between student age, year of study, and their clinical learning experiences. Students found the ward environment, clinical teacher expertise, and knowledge-to-practice integration to be highly satisfying elements in their clinical education.

The Importance of Learning with Patients: Post-Pandemic Takeaways on Learning Professionalism in Clinical Settings.

Public demands for high-quality healthcare require medical schools to ensure that physicians attain various competencies, including professionalism and humanism. This can be accomplished through various interactions and socialisations within the healthcare community. These meaningful learning experiences become more critical as students face unpredictable learning opportunities in clinical settings. However, professional development focuses on lapses, remediation and knowledge retention rather than its practice. To nurture professional and humanistic physicians, this study explores how medical students perceive learning professionalism in clinical settings. This is a qualitative phenomenology study involving medical students in clinical rotations at the Faculty of Medicine Universitas Indonesia. Respondents were chosen through a purposive sampling method that considered their gender and clinical years. Data were collected through focus group discussions (FGDs) and thematic analysis was used. Three FGDs were conducted with 31 clinical students. Learning professionalism in clinical settings presents challenges, including the hidden curriculum (HC), limited exposure to patients and the clinical learning environment because of the social restrictions caused by the COVID-19 pandemic. The tailored strategy to learn professionalism in the clinical learning environment was more teacher-driven, including role modelling, debriefing, providing feedback and teaching context-specific knowledge on professionalism, followed by patient interactions. The significance of students' interactions with the clinical learning environment, especially with patients and clinical teachers as role models, is the key to learning professionalism in clinical settings. This finding is an important takeaway in curriculum design for professionalism.

Perceptions of Justice in Clinical Learning Environments: Development and Validation of an Organizational Justice Measure for Medical Trainees.

This study aimed to develop an instrument to measure medical trainees' perceptions of justice in clinical learning environments. Between 2019 and 2023, the authors conducted a multiyear, multi-institutional, multiphase study to develop a 16-item justice measure with 4 dimensions: interpersonal, informational, procedural, and distributive. The authors gathered validity evidence based on test content, internal structure, and relationships with other variables across 3 phases. Phase 1 involved drafting items and gathering evidence that items measured intended dimensions. Phase 2 involved analyzing relevance of items for target groups, examining interitem correlations and factor loadings in a preliminary analysis, and obtaining reliability estimates. Phase 3 involved a confirmatory factor analysis and collecting convergent and discriminant validity evidence. In phase 1, 63 of 91 draft items were retained following a content validation exercise gauging how well items measured targeted dimensions (mean [SD] item ratings within dimensions, 4.16 [0.36] to 4.39 [0.34]) on a 5-point Likert scale (with 1 indicating not at all well and 5 indicating extremely well). In phase 2, 30 items were removed due to low factor loadings (i.e., < 0.40), and 4 items per dimension were selected (factor loadings, 0.42-0.89). In phase 3, a confirmatory factor analysis supported the 4-dimension model (χ2 = 610.14, P < .001; comparative fit index = 0.90, Tucker-Lewis Index = 0.87, root mean squared error of approximation = 0.11, standardized root mean squared residual = 0.06), with convergent and discriminant validity evidence showing hypothesized positive correlations with a justice measure (r = 0.93, P < .001), trait positive affect (r = 0.46, P < .001), and emotional stability (r = 0.33, P < .001) and negative correlations with trait negative affect (r = -0.39, P < .001). Results indicate the measure's potential utility in understanding justice perceptions and designing targeted interventions.

Do nursing students' attitudes to clinical practice training affect the levels of vocational motivation?

It is extremely important for nursing students to be professionally motivated to train qualified future professional nurses. Students' vocational motivation is affected by their experiences in clinical and academic learning environments. The aim of this study was to investigate the correlation between the vocational motivation levels of nursing students and their attitudes toward clinical practice. 292 nursing students participated in the cross-sectional, descriptive study. The Student Information Form, Nursing Students' Attitudes Towards Clinical Practices Scale, Motivation Sources and Problems Scale (MSPS) were used to gather the data. The average score for students' attitudes toward clinical practice was 107.08±18.13, while the total score for MSPS stood at 3.80±0.63. A positive correlation was identified between the attitude toward clinical practice and vocational motivation levels (r = 0.367; p < 0.001). There were positive correlations between the intrinsic motivation (r = 0.572; p < 0.001) and extrinsic motivation (r = 0.58; p < 0.001), and negative correlations were observed between the negative motivation (r=-0.324; p < 0.001) and the attitude toward clinical practice scale. There were positive correlations between belief and expectation (r = 0.492; p < 0.001) and positive approach (r = 0.532; p < 0.001) with the MSPS. In the multiple regression analysis, intrinsic motivation, extrinsic motivation, satisfaction with studying nursing, and participation in vocational courses were determined as effective predictors of attitudes towards clinical practice and explained 60.4% of the variance. The study concluded that nursing students' attitudes toward clinical practices affect vocational motivation. Clinical learning environments should be arranged in a way to increase the motivation level of students towards professional learning.

Addressing unprofessional behaviors in the clinical learning environment: lessons from a multi-year virtual, intergenerational, interdisciplinary workshop

ABSTRACT Introduction Optimizing the clinical learning environment (CLE) is a medical education priority nationwide. Materials and Methods We developed a virtual, one-hour workshop engaging students, housestaff and faculty in small-group discussions of five case scenarios adapted from reported unprofessional behaviors in the CLE, plus didactics regarding mistreatment, microaggressions and bystander interventions. Results Over two sessions (2021–2022), we engaged 340 students and 73 faculty/housestaff facilitators. Post-session surveys showed significant improvement in participants’ ability to recognize and respond to challenges in the CLE. Discussion Our innovative workshop, including scenarios derived from institutional reports of unprofessional behaviors, advanced participants’ knowledge and commitment to improve the CLE.

Examination of the Dundee Ready Educational Environment Measure (DREEM) Model-Based Educational Quality in the Clinical Divisions of Semnan University: A Descriptive Study.

It is widely recognized that there is a significant correlation between the quality of the learning environment and the level of satisfaction and achievement of students. To enhance the quality of education, it is vital to discern and rectify any inadequacies or deficiencies within the learning environment. Since the examination of strengths and weaknesses of the clinical learning environment provides valuable information to educational managers in improving the quality of education, the primary objective of this study was to examine the educational atmosphere prevalent in the principal clinical departments of the academic medical centers affiliated with Semnan University of Medical Sciences. The investigation was carried out based on the principles of the Dundee Ready Educational Environment Measure (DREEM) model. The present study was conducted with a descriptive-analytical approach which consisted of 232 trainees and interns affiliated with the departments of pediatrics, gynecology, internal medicine, and surgery. Sampling was done by census method. Then, a standard questionnaire was designed based on the DREEMmodelin Google Forum and its link was uploaded by representatives in class groups and channels. The data were collected within a period of three months and then were statistically analyzed using SPSS, version 24(IBM Corp., Armonk, NY). Based on the results, the mean age of students was 23.92 years. The mean score of the educational environment of interns and stagers based on the questionnaire was 122.45 and 143.35, respectively. Regarding the mean score of the educational environment, a statistically significant difference was observed between pediatric and internal medicine (P-value<0.001), and surgical and internal medicine departments (P-value=0.03). In general, the educational environment was evaluated as semi-optimal from students' point of view; thus, it appears imperative for university officials to allocate greater attention toward enhancing the quality of the learning environment by devising more meticulous plans and engaging in consistent self-assessment of the educational landscape.

What the experts see: A qualitative analysis of the behaviors of master adaptive learners in emergency medicine.

The Master Adaptive Learner (MAL) model postulates that learners develop adaptive expertise through cycles of self-regulated learning. Despite a robust theoretical basis, the actual observable behaviors of MALs are not well characterized. We sought to define behaviors that characterize MALs within emergency medicine (EM) training. Using a constructivist grounded theory approach, we analyzed semistructured interviews with expert EM educators. These experts reflected on observable behaviors as well as factors in the clinical learning environment that may modulate these behaviors. We recruited using purposive sampling until thematic saturation. We identified four overall themes, of which three described groups of learner behaviors and a fourth described modifiers of these behaviors. Learner behaviors include: (1) critical interrogation of practice, (2) intellectual risk-taking, and (3) intentional curation of a learning network. Critical interrogation of practice encompasses several observable behaviors including learner-driven feedback conversations, independent synthesis of clinical information, appropriate deviation from algorithms based on their conceptual understanding of core principles, intentional use of case variation and hypothetical questioning, and continuous refinement of decisions. MALs also engage in intellectual risk-taking for their development by communicating clinical decision-making processes even at the risk of being wrong, openly addressing errors and gaps, and intentionally seeking out uncomfortable experiences. Intentional curation of a learning network is the deliberate development of a consortium of trusted individuals who serve as mentors and sounding boards. We also identified a fourth theme related to the expression of learner behaviors: learning environment modulates behaviors. Active promotion of psychological safety is necessary for learners to express these behaviors. This safety is mediated through trusting relationships and expert supervisors who serve as colearners and role models. We present several behaviors that allow identification of MALs among EM trainees. These data expand our understanding of MALs and the critical influence of the learning environment. Identification of these behaviors may allow for more precise categorization of targeted curricular interventions and meaningful learning outcomes.