Clinical Learning Environments

What are Clinical Learning Environments?

Kern National Network | Clinical Learning Environment Clinical Learning Environments (CLEs) are essentially anywhere students (and other learners) learn about patient care—ranging from the bedside to the team rooms, and from the emergency department to the operating room, to the clinic and the hospital wards. Increasingly, CLEs even include the virtual spaces where telehealth is provided.

As recognized in the Josiah Macy Jr. Foundation's "Improving Environments for Learning in the Health Professions," numerous opportunities exist to ensure that CLEs encourage continuous development, well-being, meaning and purpose.

Integrating character and caring in CLEs can both enable a better response to mistreatment—an ongoing stressor that can lead to unwellness and burnout—and prevent negative events by aligning the hidden and formal curricula.

The KNN Clinical Learning Environment Initiative is focused on developing foundational knowledge and strategic approaches to create healthy CLEs by identifying and reporting on the following key issues:

Mitigating challenges to learning and patient care (e.g., learner mistreatment, microaggressions).
Identifying exemplars who role model key character traits.
Developing skills and processes to react to and report challenging events and behaviors in CLEs.

What CLE Elements Support Learner Well-Being?

Team members in this KNN initiative have conducted a systematic literature review and identified the following to significantly impact learner well-being:

Stressors in Learning Environments
Inclusion
Faculty and Peer Relationships
Professionalism
Mental Health/Well-Being Curricula
Hours/Shifts
Feedback Systems
Pedagogies

The most robust findings have to do with academic stressors, relationships, professionalism and well-being curriculum. Regarding stressors, while pedagogy may impact motivation and performance, it seems workload, time spent in lecture and on tests, as well as frequency of testing have a larger impact on learner well-being. Promoting faculty-student relationships and creating a sense of community among students may be the simplest way to improve learner well-being. This is especially important for underrepresented and traditionally marginalized groups. Addressing faculty and resident negativity, which of course has its roots in their own well-being, is a promising avenue for addressing learner well-being. Including well-being didactics in curricula also has positive effects.

The Impact of the Learning Environment on Learner Well-Being: A Systematic Review of the Literature

Presented by David Cipriano, PhD (MCW) at the October 2019 CENTILE Conference.

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How Does Character Contribute to CLEs?

Facilitating medical students' character development is critical to their professional identify formation, personal reflection, and ultimately professionalism. This KNN initiative is exploring the use of reflection to cultivate character in CLEs by creating and supporting opportunities for medical students to reflect on, and write about, opportunities to employ character traits, such as courage.

Reflective narratives themes have included:

Meaning of courage in medicine.
Courage exemplars.
Missed and future opportunities to employ courage in CLEs.

Medical students have found reflection, narrative, and small group discussions exploring character moments in CLEs valuable and have encouraged expansion of the program.

Use of Reflection to Cultivate Character in the Clinical Learning Environment

Presented by Marty Muntz MD, FACP, Ryan Spellecy PhD, Catherine Ferguson MD, and Kathlyn Fletcher MD at the October 2019 CENTILE Conference.

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How Can We Facilitate Ongoing Improvement?

Each school is unique and has a different range of resources, opportunities and barriers for continuous improvement in clinical learning environments. The seven schools in this initiative have shared approaches, successes and ongoing challenges. Some best practices for monitoring performance and addressing concerns in clinical learning environments include:

Regularly reviewing individual school performance on national surveys such as the AAMC Graduation Questionnaire, AAMC Year Two Questionnaire and ACGME Resident and Faculty Surveys.
Developing trusted internal processes for reporting and effectively addressing negative behaviors and mistreatment of learners.
Capturing data from course evaluations or other internal surveys to identify areas of local concern, monitor trends across site and time, and identify exemplars.
Establishing mechanisms (i.e. committee, annual report, celebration) to draw attention to the importance of the clinical learning environment and get people working together on improvements.

For more specific ideas on how you can “Make Measures Matter” at your institution, see resource below.

Assessment of Learning Environments in Medical Education: Instruments and Best Practice

Presented by Regina Russell PhD (Vanderbilt School of Medicine), Andrea Leep Hunderfund MD, PHPE (Mayo Clinic Alix School of Medicine), Marty Muntz MD, FACP (MCW), Sandrijn van Schaik MD, PhD (UCSF School of Medicine) at the UCSF Developing Medical Educators of the 21st Century Conference in February 2020.

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