Ova Emilia*, Leah Bloomfield**, Arie Rotem

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Learning activities and resources: This factor comprised generic activities, such as orientation sessions, lectures, tutorials, ward rounds, bedside teaching, meetings with advisers, direct supervision and feedback, access to the library. The majority (74.4%) stated that these types of activities were provided at a low to moderate level; very few students (4.8%) reported a high level and 20.8% reported that they were not provided.

Opportunities to practise skills: This factor comprised the department-specific skills, which related to the specific objectives of each rotation. Students’ experiences varied widely. Taken across all departments, 67.8% of students performed at least one skill on at least one occasion; few (12.7%) neither observed nor performed any skills. Looking at individual departments (Table 5) there were three departments where more than 20% of students neither saw nor performed any skills and six departments where more than a third (35%) of students saw skills demonstrated but had no opportunity to perform them.


The most frequent methods of assessment were orals (90.1%), assignments (86.2%), case presentations (80.3%), skill performance (69.3%) and written exams (50.2%). Less than half (40.2%) were satisfied with their assessment or considered it fair (42.6%). About one third (36.8%) had not been told how they would be assessed and felt that their grade did not reflect their level of competence (33.0%).

The influence of gender, seniority and career intention.

 Univariate analysis (see Table 4) showed that personal characteristics had a minor influence on perceptions of the learning environment. Women perceived autonomy, supervision, opportunities to practice, and resources slightly more positively than men. Career intention and seniority interacted with perception of activities. Fifth year students and those who intended to become specialists perceived that there were more learning activities than fourth year students and those who wanted to be general practitioners.

Departmental differences

 Univariate analysis of variance showed that differences between departments were highly significant on all CLE scales (see Table 4). We excluded departments with fewer than 10 responses. Tukey-HSD post-hoc analysis showed that the Conditions for Learning scales tended to band together, that is, when emphasis on teaching and learning was high, scores on autonomy, supervision, social support, role clarity, variety were also high, and conversely.



We used multiple pair-wise comparisons for each scale for a deeper insight into the departmental scores. Departments tended to score high on many scales, or low on many scales. For example, the two highest-scoring departments had significantly higher scores than other departments on five and six respectively of the seven conditions for learning scales. The same occurred for the three lowest scoring departments.


The survey emerged as a valid, reliable, rapid self-report tool for characterising the clinical learning environment in a tertiary hospital in Indonesia. As the seven scales of Factor 1 (the conditions for learning) showed similar psychometric properties to the scales in the study of junior doctors learning in Australian hospitals, we tentatively conclude that the survey can be used to portray the social and organisational aspects of hospital learning generally, although this conclusion should be validated using larger studies in other countries.

We do not regard self report as a limitation but as appropriate for a study of learning, as it is students’ perceptions of their learning environment that determines the way they approach learning tasks (Ramsden, P & Entwistle, NJ, 1981). In this way the instrument differs from some more ‘objective’ types of hospital audit tools (Callaghan, IH & McLafferty, H, 1997; Shailer, B, 1990). As the scales are positively correlated, it is technically possible to arrive at a global score for the conditions for learning, however we feel, as do (Feletti, GI & Clarke, RM, 1981) that there is value in examining the individual scales.

The survey revealed the clinical learning environment in the study hospital as moderately favourable. Between 46.2% and 65.7% of students perceived the Conditions for Learning scales positively. Around 20 to 25% of students had negative perceptions and 13 to 26% were non-committal. Generic learning activities and resources (Factor 2), such as outpatients clinics, ward rounds, bedside teaching lectures, tutorials, access to the library, were provided at a low to moderate level. About one third of students overall did not perform any of the skills that were considered appropriate for their rotation (Factor 3). This was disappointing but not unusual (Dolmans, DH, Wolfhagen, HA, Essed, GG, Scherpbier, AJ, & Van Der Vleuten, CP, 2001; Remmen, R, 1998).

We are confident that there was minimal confounding by personal characteristics. Women in our study perceived certain attributes slightly more positively than men, an interesting finding, given the mixed findings on gender-related perceptions and responses to clinical learning (de Saintonge, DMC & Dunn, DM, 2001; Robins, LS, Gruppen, LD, Alexander, GL, Fantone, JC, & Davis, WK, 1997) and the current debate about the ‘chilly climate’ perceived by women in higher education in some western universities (Prentice, S, 2000). Our study did not find deterioration in the environment as students progressed through medical school (Pololi, L & Price, J, 2000) however we did not expect this as they were in the senior years.

The survey detected clear differences between departments and has considerable potential for suggesting specific ways to improve the quality of the learning environment, although we caution that sufficiently large numbers of responses are needed if it is to be used for this purpose.

We hypothesise that the favourable conditions for learning defined by Factor 1 are necessary but not sufficient for a positive learning experience. In other words, organisational and socio-cultural interactions enable or inhibit students’ access to the formal, technical elements of the environment, such as the organised activities, resources and opportunities for practice that are represented by Factors 2 and 3. We were unable specifically to test this hypothesis in this cross sectional study, however there is support for a “gateway” hypothesis from the qualitative data and from a second arm of the study in which we followed a subset of 39 students through a series of rotations. These findings, which are not reported here, suggest areas for future research.

Nursing research indicates that the preceptor is a key figure and gatekeeper in creating the conditions for learning (Hart, G & Rotem, A, 1994; Saarikoski, M, Leino-Kilpi, H, & Warne, T, 2002). Our study indicates that the role of the individual preceptor is only one element in a web of social and organisational interactions that determine the conditions for learning. As medical students usually have a variety of people acting in a supervisory role, it may be more important that all staff in the department share an understanding of staff and student roles, relationships, expectations and the limits of student autonomy (Seabrook, MA, 2003).


The Clinical Learning Environment survey instrument is a valid, reliable and practical survey for monitoring students’ perceptions of learning environments. It has similar psychometric properties to the tool developed for Australian junior medical officers and so shows promise as a widely applicable, culture-neutral instrument, although additional confirmatory studies are needed.

The seven scales of the conditions of learning are not readily separated and appear to constitute a holistic construct. Autonomy, role definition, social support, workload, variety, feedback and supervision all contribute to a department’s emphasis on teaching and learning. When adequate, these conditions appear to enable students to make best use of activities, resources, and opportunities to practise clinical skills.

The survey instrument allows differences in departmental culture to be quantified. We are not suggesting that it be used to rank or compare departments; rather, we prefer to use the instrument as a source of evidence to guide review and discussion of a department’s educational policies, practices and resources. It could be used to monitor trends within a department, for example, to ensure that successive batches of students are offered comparable experiences. It could be used to monitor the impact of curriculum change, to contrast actual and preferred environments and to compare staff and students’ perceptions of the same environment. The instrument can also be used for research, for example, to test hypotheses about the relationship between environmental variables and the development of professional competency.



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