The medical educational environment has been studied extensively in the past decades

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Data abstraction

We ascertained which educational environment instruments were used to build the medical ones that were included in our study and retrieved the publications describing the development processes of these underlying instruments. We examined these publications to find out whether these instruments were founded on any theoretical frameworks. We repeated this process for any previously developed educational environment instruments that were used to construct them. We evaluated the usefulness of any theoretical frameworks found. We emanated from the point of view that – in order to be acceptable as a theoretical framework – frameworks should cover the entire environment, have been tested repeatedly and be generally acknowledged rather than only being a speculative view or idea (Rees & Monrouxe, 2010). We consider a theoretical framework relevant and useful if it clearly delineates which components of the educational environment should be measured in order to obtain an adequate and complete picture of its quality.


Search results

The electronic search yielded 579 records. The individual databases yielded 162 (Academic Search Premier), 33 (CINAHL), 167 (EMBASE), 29 (ERIC), 105 (MEDLINE), 0 (PsycARTICLES) and 83 records (PsycINFO) respectively. After removing duplicates, 324 records were left for screening (see Figure 1). Of these, 309

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records were discarded as they did not meet the inclusion criteria. Then the full-text articles of the remaining 15 records were assessed for eligibility. Six studies were excluded either because they concerned an abstract, were written in a non-English language, or because the focus of the questionnaire was too narrow or not purely on educational environment. Our manual search yielded one additional, relevant study. A search of the reference lists of the 10 studies resulting from our search yielded one additional instrument that we included for its relevance.
Overview of medical education environment instruments

Inspection of the scales of the 11 included medical education environment instruments reveals that the instruments demonstrate several similarities (see Table 1).

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For instance, teaching, supervision and training are recurring themes, as are perceptions of atmosphere, emotional climate and social support. The same is true for perceptions of learning opportunities, orientation to learning, workload, goal direction and emphasis on scholarship. Nevertheless, the instruments also display many differences, for instance, in numbers of scales, which range from three to twelve. These differences may partly be ascribed to the fact that some instruments combine several concepts in one scale, whereas others measure these concepts separately. For example, the STEEM and the ATEEM measure perceptions of workload, supervision and support in combination (Cassar, 2004; Holt & Roff, 2004), whereas the DR-CLE, the D-RECT, the PHEEM and the SLHS measure one or more of these concepts using separate scales (Bloomfield & Subramaniam, 2008; Boor et al., 2011; Roff et al., 2005; Rotem et al., 1995). In the same way, the PEEM combines perceptions of teaching and learning (Mulrooney, 2005), whereas the DR-CLE measures these aspects separately (Bloomfield & Subramaniam, 2008). Closer inspection on item level reveals another type of dissimilarity: different instruments use similar items to measure different concepts:

  • items about good relationships with the teacher are used to measure perceptions of the trainer as well as perceptions of atmosphere (Mulrooney, 2005; Holt & Roff, 2004).

  • items on workload are used to measure perceptions of workload/supervision/ support and perceptions of role autonomy (Holt & Roff, 2004; Roff et al., 2005).

  • items on learning opportunities are used to measure perceptions of learning opportunities as well as perceptions of role autonomy (Cassar, 2004; Roff et al., 2005).

  • items on learning objectives are used to measure perceptions of role clarity and perceptions of teaching (Rotem et al., 1995; Roff et al., 1997).

In-depth search for theoretical frameworks

Figure 2 illustrates the process of investigating instruments used in the development

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of the medical educational environment instruments. The most recently developed instruments are positioned at the top of the scheme, with the 11 medical educational environment instruments that formed the start of our in-depth study in bold typeface. Any underlying educational environment instruments are indicated with arrows. The Surgical Theatre Educational Environment Measure (STEEM) (Cassar, 2004), for instance, was developed using the Clinical Learning Environment Inventory (CLEI) (Chan, 2001) which was in turn based on the College and University Classroom Environment Inventory (CUCEI) (Fraser et al., 1986). Theoretical frameworks that were used in development processes are highlighted in boxes. For example, the theoretical framework of Moos was used to guide the construction of the CLEI (Chan, 2001), the CUCEI (Fraser et al., 1986) and the Individualised Classroom Environment Questionnaire (ICEQ) (Rentoul & Fraser, 1979).

Our in-depth investigation yielded two theoretical frameworks. The first framework was the work of Murray (Murray, 1938). Murray initially focused on formulating a conceptual scheme for describing personality. When he realized that behavior can not only be attributed to an individual’s personality, but also to the person’s perceptions of the environment, he also focused on the environment. He attempted to operationalize person and environment concepts in commensurate terms. However, Murray casted doubt on his own results. He realized that his criteria for formulating these concepts were not univocal and his scheme was imperfect: the criteria for setting up the categories were not unequivocal (p. 716) and resulted in no more than ‘a rough, preliminary plan to guide perception and interpretation’ (p. 143) (Murray, 1938). In addition, the long lists of variables resulting from his efforts are described as rather unstructured and Murray’s work as not offering a systematic theory nor central findings (McAdams, 2008). Therefore, we decided not to test the applicability of this framework for evaluating the medical educational environment.

The second theoretical framework that we found was the framework formulated by Moos (1973; 1974). According to Moos, each human environment – irrespective of the type of setting (e.g. psychiatric ward, correctional institution, military training, classroom, therapeutic group, work environment or family setting) – can be described by common sets of dimensions. Moos conceptualized these sets of dimensions in three broad domains:

1) Personal development or goal direction dimensions, which relate to the basic goals of the specific environment – they assess the basic directions along which personal growth and self-enhancement tend to occur. In educational settings, this domain pertains to achieving the aims of education. An educational environment scoring high on the goal direction domain is characterized clarity about learning objectives, relevant learning content and constructive criticism.

2) Relationship dimensions, which assess the extent to which people are involved in the setting, support and help each other and express themselves spontaneously, freely and openly. A favourable relationship domain is characterized by open communication, friendliness, social and interpersonal support, cohesion and feelings of group spirit. Dimensions representative of positive relationships in educational settings are student involvement, affiliation, (emotional) support and teacher support.

3) System maintenance and system change dimensions, which measure the extent to which the environment is orderly and clear in its expectations, maintains control, and responds to change. Examples of the basic dimensions representative of this domain in educational settings are order, organization, rule clarity, teacher control, student influence and innovation. Since the clinical learning environment is part of a work setting, work pressure and physical comfort – a dimension that is, in work settings, representative of this domain – may also be relevant.

Given that Moos’ theoretical framework has been validated in different contexts, including education, we chose to test the applicability of this framework for the medical educational environment.

Study 2 - Applicability of the theoretical framework
To find out whether Moos’ theoretical framework is applicable to the medical educational environment, we investigated whether the items of medical education environment instruments could be mapped into it. Since we did not succeed in obtaining the MSLES (Marshall, 1978) and the LEQ (Rothman & Ayoade, 1970), we focused our content analysis on the DR-CLE questionnaire (Bloomfield & Subramaniam, 2008), the D-RECT (Boor et al., 2011), the STEEM (Cassar, 2004), the ATEEM (Holt & Roff, 2004), the PEEM (Mulrooney, 2005), the DREEM (Roff et al., 1997), the PHEEM (Roff et al., 2005), the Survey of Learning in Hospital Settings (Rotem et al., 1995), and the MSEQ (Wakefort, 1981).

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