Education and training does not just depend on the teacher / learner dyad in isolation. They are just part of a bigger training environment. We are probably well aware of the micro environment of the practice or clinical setting which includes attitudes and involvement of the non-supervisor medical staff, the busyness of the service (in either direction), the variety of clinical cases, the supportiveness of non-medical staff and so forth. These can be even more variable in community settings (compared to hospital) and can be harder to control. However, they may often need to be accounted for. If a particular practice has a patient load that is largely acute presentations, repeat scripts and medical certificates with little continuity of care (not uncommon in some settings) then educators should be aware of this and able to direct the registrar to a different type of experience in a later term It can be more subtle within a practice where “female problems” are directed to a female registrar who then gains less experience in other areas. A registrar may feed back that a supervisor is not very helpful but yet the environment is conducive to learning because office staff are supportive and other medical staff are knowledgeable and involved. The one thing you can say is that the issues are complex and a training system needs to take account of this.
There are a few points made in the following article (about education in residency training) regarding the importance of the “intangibles of the learning environment”. The author claims that “At its best, the residency experience must be conducted as professional education, not as vocational training.” It goes further than mere training or credentialling and should focus on things that are obvious to many good supervisors : the assumption of responsibility, reflective learning, primacy of education and continuity of care. http://www.jgme.org/userimages/ContentEditor/1481138241158/06_jgme-09-01-01_Ludmerer.pdf However, I do not agree with the negative interpretation of the limiting of work hours and suspect the principle of continuity should be addressed in other ways. A positive training environment can certainly encourage the learners to be curious about the outcomes of patients they see in the context of good handovers and teamwork.
He suggests there is a need to prepare “residents to adapt to the future, not merely learn for the here and now…excellency in residency training is not a matter of curricula, lectures, conferences, or books and journals…. Nor is it a matter of compliance with rules and regulations. Excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of trainees, the opportunity to assume responsibility, the freedom to pursue intellectual interests, and the presence of high standards and high expectations.” You can sense his frustration at the increasing bureaucratisation in learning environments. I am aware of many great supervisors in general practice who do all of this almost intuitively and we rely on their skills and commitment when broader systems are not adequate.
It is not so immediately obvious that the macro environments also have a significant influence on the learning culture. These can include the ethos of a hospital, training organisation or government policy frameworks.
If the varying stakeholders (government, colleges, standard setters, accreditors, funders) emphasise outcomes and competencies, this can move the learning environment towards one that focusses on assessment and box ticking. This may have benefits but there may be intangible losses which are not acknowledged. If efficiencies are sought through larger institutions and faculty mergers, then the interpersonal nature of education may be lost.
Standardisation may increase the quality of training or lead to a lowest common denominator approach and the implementation of IT platforms is extremely unpredictable in its outcomes. At its worst, educational quality ends up at the mercy of unresponsive systems and learners and teachers feel they are part of an industrial process. At its best, resources become more accessible to learners and reflective and self-directed learning can be enhanced.
In the clinic setting a positive learning environment is encouraged when the learner feels free to ask questions and when they observe a culture of learning in their colleagues; where all staff acknowledge the importance of education and the learning task; where the supervisor is able to admit when she doesn’t know something and where the learner is treated with respect. Learning is facilitated when there is sufficient challenge matched by the appropriate level of support – the concept of “flow” (another topic of its own) – which is not always easy to achieve and is a shifting dynamic. The learning environment must also be safe for learner and patient and this often relates to the quality of supervision.
There are other learning environments which include the “workshop” setting. There is more to it than standing up in front and presenting relevant or required content to a group of learners. The focus of evaluation is often on the presenter but a fantastic performer or an attractive collection of slides does not always ensure the most effective learning. Similarly, pre-prepared learning objectives may have limited relevance to the learning that is actually occurring. The size of the group will affect how active or passive the process is (300 is very different to 30). Consider the members of the particular group of learners – are they at the same level, do they already know each other, do the presenters know them, have they travelled far? What about the size of the rooms and the acoustics? Are the small group facilitators well prepared? Which of the educational staff takes note of (or has power to influence) these “small” but important issues.
In the bigger picture, consider the effect on the learning environment if service delivery is always prioritised over teaching or if the educational staff have minimal professional development to develop their skills. The “intangibles” of the learning environment that lead to excellence include the unintended consequences of policies and rules. Learners are enthused to extend their knowledge and skills when they are inspired by mentors, when they can communicate with their educators and interact with their peers, when they feel supported by their supervisors and when the parameters of training include sufficient flexibility to allow for individual needs and rates of progression.
Over the last couple of decades there has been talk of both vertical and horizontal integration in teaching and learning environments. Some of this has been ideological, idealistic or pragmatic. It is affected by the size of institutions, the remoteness of training locations and the training requirements of various health professions. It has been influenced somewhat in Australia by the waxing and waning of funding for the PGPPP (pre-vocational general practice placement program) and it is no doubt also affected by practice economics, student numbers and reimbursement (or otherwise) for teaching. The GP supervisors group has written about this from a supervisor viewpoint http://gpsupervisorsaustralia.org.au/wp-content/uploads/GPSA-Vertical-and-Horizontal-Learning-Integration-in-General-Practice-Apr2014.pdf (before the more recent significant changes to the structure of Australian GP training) and there are some notable examples of practices who make a conscious effort to create a learning environment.
Consider the learning environments that you are part of and the factors that are influencing its educational quality. I suggest discussing these with colleagues and considering the broader issues when you are evaluating your teaching sessions and the experience of learners. We want learners to bloom (not shrivel up like the pot plants on my windy and salty balcony) and for that they need the right environment! Bear in mind that you can make assumptions about the factors that create a positive learning environment but, ideally, it would be best practice to actually try to measure this. The validity of educational methods is very context dependent.
Educators may have limited power to influence decision making at many levels but we have a professional responsibility to inform decision makers when the learning environment can be improved and, especially, when it is under threat.