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



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Discussion
The aims of this study were 1) to find a comprehensive theoretical framework that outlines the key concepts that should be measured in ascertaining the quality of the educational environment, and 2) to test the applicability of this framework. We hoped to find out which concepts are essential to the quality of the educational environment and whether medical educational environment instruments measure these concepts. Although, in general, medical educational environment instruments lack solid, established theoretical frameworks, our snowballing method led to a framework that seems sensible and useful for formulating a theoretical framework tailored to the (medical) educational environment (Moos, 1973; 1974). Moos’ framework defines three domains as the key elements of human environments: personal development or goal direction, relationship, and system maintenance and system change dimensions. This framework has been validated in different contexts, including education.

Our second study showed that the great majority of the items of nine contemporary medical educational environment instruments could be mapped unto Moos’ framework. Two-thirds of the items were allocated straight to one of the domains and a quarter pertained to more than one domain. Closer inspection of our results showed that in the medical educational environment context, the contents of the three domains relate to goal orientation (the content and aims of education), relationships (an open and friendly atmosphere and affiliation) and organization/regulation. This trichotomy – goal orientation, relationships and organization/regulation – may be valuable as a theoretical framework for (current and future) medical educational environment measures.

The fact that a huge number of items could be mapped unto the framework supports the validity and comprehensiveness of Moos’ general theoretical framework for characterizing human environments. The outcomes of our second study indicate that tailoring this framework to our context implies that evaluating the quality of medical educational environments requires assessment of goal orientation, relationships and organization/regulation in the environment. Structuring the contents of instruments into these domains may benefit the quality of medical educational instruments. Our study showed that part of the items could be assigned to more than one domain. It is not surprising that not all items could be allocated straight to a single domain, since they were not constructed with the framework in mind. Focusing these items unambiguously on only one of the three domains may contribute to forming coherent scales, which may, in turn, enhance the reliability and validity of the instrument in question.

The validity and comprehensiveness of the framework that we found is supported by previous research. First, Moos found these three domains in nine vastly distinct kinds of settings (Moos, 1974). Second, a similar framework was applied in organizational research into the influence of climate on attitude, satisfaction and performance in an organizational setting (Ostroff, 1993). This framework was developed independently from Moos and comprises three broad categories of climate perceptions, namely perceptions of the affective (interpersonal and social relations), cognitive (e.g. growth and autonomy) and instrumental aspects (e.g. hierarchy, structure) of the organizational climate. It was commended as a comprehensive classification of organizational climate perceptions that reflects the integration of existing literature (Carr et al., 2003). Third, qualitative studies yielded similar classifications. For example, a study of students’ perceptions of the theatre learning environment yielded three domains as important for successful learning: educational task (which pertains to the content and aims of education), social relations, and physical environment and emotional impact of the work (Lyon, 2003). A study by Dornan et al. (2005) – focused on the conditions essential for optimizing learning in the clinical environment – revealed three kinds of teacher support (pedagogic, affective and organisational) that also correspond closely with the three domains of educational environment that we identified.

A possible limitation of our study is that we did not statistically (factor) analyse whether the items of the medical educational environment instruments fit the framework. Future research should focus on validating the theoretical framework with quantitative data. To ascertain the value and practical usefulness of the framework, further validation studies should examine whether students’ perceptions of their educational environment (in terms of the three domains) are related to student involvement, satisfaction and achievement. In addition, the outcomes of these studies should be compared to findings of similar research using the original scales.

A second limitation of our study might be the quality of the instruments used in our study. Despite the fact that these instruments were not based on any theoretical framework, we are of the opinion that they constituted a useful point of departure for our in-depth search for a theoretical framework. They were developed carefully by applying thorough qualitative research methods, in several instances even different qualitative research approaches concurrently, like grounded theory (using focus groups and/or Delphi panels), reviewing literature and/or using existing instruments. Besides, they were published in peer-reviewed journals, which represents an acknowledgement of their quality. Last but not least, their wide coverage of environment aspects makes them suitable as an adequate basis for judging the validity of any theoretical frameworks found.

The theoretical framework that we propose for the educational environment is based on Moos (1973; 1974). We realize that Moos’ theory has been developed several decades ago. In the meantime, medical education is broadened with sociocultural perspectives, like situated learning and communities of practice, which may be relevant for measuring educational environment quality (Van der Zwet et al., 2011). Sociocultural theory is considered as a promising and powerful theory that may be valuable for explaining how learning occurs in dynamic contexts like clinical educational environments (Bleakley, 2006). Characteristic for sociocultural theory is that the interaction and collaboration with others is acknowledged as influencing students’ learning processes, both through learning knowledge and skills from others, and through becoming familiar with the norms, cultural beliefs and attitudes existing in the communities to which they (the students) are being introduced. The emphasis on interaction and collaboration with others implies that (interpersonal) relationships – belonging to the second domain – are important for students’ learning processes. In addition, learning how to collaborate with others is an important goal to achieve which is related to the first domain, goal direction. Furthermore, the importance that sociocultural theory attaches to interaction and collaboration with others may also have implications for the way education and learning is organized and/or regulated. In our opinion, the proposed framework for measuring medical educational environment quality allows for incorporating these sociocultural perspectives. We noted that, from all the instruments included in our study, the D-RECT (Boor et al., 2011) contains most items representing sociocultural aspects. We also found that all these items could be related to our framework. Given these findings, we think that the proposed theoretical framework and sociocultural theory may supplement each other and thus help to carry the medical education field forward. We also think that the proposed framework may add to the understanding of the functioning and effectiveness of situated learning and communities of practice (Lave & Wenger, 1991; Dornan et al., 2007; Fuller et al., 2005; Ellström, 2001).

The current theoretical framework may also add to other, related fields that are important to the quality of students’ learning processes. It may, for instance, add to the understanding of the functioning and effectiveness of supervision: in an extensive literature review Kilminster & Jolly (2000) highlight supervision relationship, feedback, and trainee control over the supervisory process and finding sufficient time for supervision as the most important features of effective supervision. These key features clearly correspond with the domains relationships, goal orientation, and organization/regulation, respectively. In a similar way, the framework may add to the understanding of roles and quality of clinical teachers and to the improvement of (clinical) teaching (Harden & Crosby, 2000; Ramani & Leinster, 2008; Skeff, 1988; Fluit et al., 2010).

The merits of the proposed theoretical framework are that it clearly delineates three distinct educational environment domains, or – in other words – three distinct sets of common educational environment dimensions. It ensures coverage of the essential components of the environment and, at the same time, enables educators in practice to tailor evaluations to specific settings. The categorization into goal orientation, relationships and organization/regulation may help educators restructure existing instruments or develop new ones in such a way that they cover the entire educational environment adequately. In addition, the framework enables multi-site research on a conceptual level: if, for example, relationships turn out to be the educational environment domain which influences student motivation and achievement most, similar outcomes should be found in different settings while using different instruments. In the same way, the framework – if commonly applied – enables educators to compare the quality of their own educational environment with that of others, even if these were evaluated using different instruments. We would even go so far as to state that tailoring items to the own setting using this theoretical framework may be a better approach to evaluation than translating and back translating instruments, since the latter bears the risk of including irrelevant cultural or contextual aspects.
In conclusion, we found a universally applicable set of domains that seems to cover the entire educational environment and comprise the essential concepts: goal orientation, relationships and organization/regulation. This theoretical framework seems valuable for research into the quality of medical educational environments and for constructing tools for assessing the medical educational environment. Therefore, we recommend this framework as a theoretical underpinning of medical educational environment measures. Ultimately, applying this framework may help to create educational environments that are conducive to learning. We hope that our study inspires educators to incorporate this framework into daily practice and research. Furthermore, we challenge researchers to test the framework with existing or new instruments. Their findings may help to achieve evidence-based practice on how to ascertain the quality of educational environment best and move the educational research field forward (Prideaux & Bligh, 2002; Eva, 2008; Eva & Lingard, 2008; Bordage, 2009).




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