14. Creating a safe learning environment

Print

Author: Lara Cooke, MD, MSc, FRCPC

Objectives

At the end of this chapter you will be able to:

  • define the learning environment and explain the rationale for prioritizing a “safe” learning environment
  • take appropriate, timely action if you identify problems in the learning environment
  • apply specific strategies for creating a safe learning environment
  • describe resources for creating a safe learning environment

Case scenario

Author: Kannin Osei-Tutu, MD, MSc, CCFP

Dr. S, a PGY 3 general surgery resident, comes to you with concerns that she is not receiving equitable access to OR cases compared to other junior residents.  As you explore the issue further you learn that she has been denied operating room access and assigned to ward duties and ED consultations for the past two weeks.  When you ask the resident why she thinks this happening, she tells you that the attending surgeon voiced concerns about her “hygiene” and told her that her “head scarf” was not suitable to be worn in the OR.  The resident, who is of Islamic faith and wears a hijab, further explains that the senior resident said there has been “an increase in post-op infections since she has been on service” and he thinks the attending is trying to “protect his patients.”

How would you respond in this situation? What can you, as program director do?:

  • To be helpful to the junior resident, the senior resident, and the attending surgeon?
  • To prevent this situation from occurring again in the future?
  • Define what has happened

1. Define what has happened?

The attending surgeon has committed both discrimination (on the basis of religion) and interpersonal racism.  Discrimination is the denial of equal treatment, civil liberties, and opportunity to individuals or groups with respect to education, accommodation, healthcare, employment, and access to services, goods, and facilities.  This also an example of 1)ethno-religious interpersonal racism in this case Islamophobia and 2) racial stereotyping.  The resident has been singled out because of her religious attire and ascribed the derogatory characteristic of uncleanliness.  She has also been assigned to complete the less desirable clinical duties in a punitive way.   The acts are egregious.

The senior resident has committed 1) interpersonal racism by ascribing disproportionate blame for an incident (increase in post-op infections) and 2) a racial microaggression by his suggestions that Dr. S’s hygiene poses a danger to patients. Racial microaggression are “everyday slights, indignities, put downs and insults that racialized individuals experience in their day-to-day interactions with people.  His comments can also be regarded as racist in that he has disparaged and ridiculed Dr. S because of her race-related characteristics and religious dress. This behavior is also egregious.

2. Determine the desired outcome: The goal is to ensure the resident’s safety and her opportunity to be fully trained.

  • For a learning environment to be safe, it must be free of racism, discrimination, harassment and intimidation.  There must be zero tolerance for such behaviors.

 Plan a course of action:

  • This incident is egregious and warrants immediate communication with the PGME Dean who may wish to involve the section chief.
  • Familiarize yourself with your institution’s policies and procedures with respect to racism, discrimination, harassment and mistreatment.  If such policies are absent considering exploring the reasons why.
  • Familiarize yourself with  your institution’s policies and procedures regarding acceptable OR head coverings.  If such a policy is absent, consider exploring the reason why.
  • Verify what happened
  • Believe the resident and validate her experience of the events. Employ a trauma-informed approach.
  • Ask the recipient of the discrimination and racism (the resident) what she is prepared to disclose and to whom.
  • Understand that the resident may feel reluctant to move forward given the inherit power imbalance, fear of reprisal, and fear of re-traumatization.
  • Encourage the resident to have a support person present who has lived experience with discrimination.
  • Clearly indicate to all parties that the behaviors are egregious and will not be tolerated.

Immediate actions that can be taken with support from the PGME dean include:

  1. Removing the resident from the learning environment
  2. Providing the resident with assurances against retaliation
  3. Removing the senior resident and attending surgeon from the learning environment and/or suspension of teaching privileges pending the outcome of an informal or formal resolution process.
  4. KEY POINT: the resident should be made aware that discrimination has occurred on “protected grounds”.  As such, she should be informed of her ability to explore options for resolution with the Human Rights Commission (HRC), in addition to the existing resolution structures of PGME and the wider institution.

Long term solutions may include:

  • Appropriate penalties/consequences for the perpetrators (the senior resident and the attending physician) pending the outcome of the resolution process.
  • Education
    • Cultural humility,  anti-Islamophobia training, anti-racism, and intersectionality (for the senior resident and attending physician)
  • Training
    • Bystander intervention training (for the senior resident)
    • Implicit bias training (for the senior resident and attending physician)
  • Culturally appropriate wellness support (for Dr. S)

Introduction

The environment in which we learn influences our learned behaviours. This concept has long been espoused by cognitive psychologists and educational theorists.1,2 While debate has continued about which factors foster learning and which ones may impede learning, it is quite clear that the environment plays a substantial role in determining what learning occurs.

In residency education, junior doctors are typically thrust into highly intense, chaotic environments for several years of training in what has traditionally resembled an apprenticeship. With the advent of competency-based medical education, residency education is moving away from the idea that “steeping” a resident in a medical environment for a fixed period of time will lead to “good tea” (read “competence”).4 Instead, the evolving paradigm for residency education focuses on creating an experience tailored to the learner’s needs in an authentic learning environment comprised of relevant experiences complemented by frequent direct observation and feedback to support gradual progression of competence.5

Although the intent of regular, low-stakes feedback is to enhance learning and improve educators’ ability to measure the progression of residents across the competence continuum during training, some suggest that the feedback given is not always taken up by the learner.6 Is it possible that learning may be impeded by factors in the learning environment? There is every indication that this may be the case.1,7,8 The state of the learning environment in which your residents train can and should be something that you, as program director, evaluate regularly. In this chapter, you will learn about what constitutes a learning environment, why it needs to be safe, and some useful tips and instruments that will help you to develop an effective educational environment for your residents.

What is the learning environment?

Defining the learning environment is an important prerequisite to establishing a safe one. We can draw from literature in the undergraduate medical education realm. Genn and colleagues define the educational environment as those things, “educational and organizational, which embrace ‘everything that is happening’ in the medical school.”9 These authors use the term “environment” somewhat interchangeably with “curriculum” and note that both environment and curriculum connote “all transactions” within the medical school. This encompasses not only direct interactions with the learner but also other observed interactions and structural, systemic and cultural aspects of the learning context.9

One way to consider breaking this down into manageable pieces is to consider “parts” of the environment individually, while recognizing that they do interact. For the purposes of this chapter, we will consider the teacher, the teacher–learner relationship, culture, and structural supports.

Why is a “safe” learning environment important?

There are many reasons to ensure that your residents train in a safe learning environment. To name a few, there are accreditation requirements, labour laws, human rights codes, the goal to successfully match the best residents to your residency program and, importantly, improved patient outcomes. Another important reason for ensuring a safe learning environment is the impact on the residents themselves. A simple way to examine this is to consider the implications of medical training when the learning environment is less than “healthy” because of intimidation, racism, sexism, or harassment.

The literature clearly shows that doctors experience higher burnout rates than any other professionals and that the rates of depression and substance use disorders in medicine are disproportionately high. Residents experience high rates of mistreatment, discrimination, racism and harassment during their training, and these correlate with poor outcomes: high rates of suicide, suicidal ideation, career dissatisfaction and burnout, to name a few.10,11 One of your priorities as program director is to ensure that your residents are well and that you have done everything within your power to ensure the environment in which they work is conducive to their well-being, to the extent that it is possible. To see residents failing, becoming unwell or leaving programs because they are inadequately supported in their learning environments is unnecessary and tragic.

As a program director, what can you do?

Recognize and act on red flags in the learning environment

There may be obvious signs that your learning environment is in trouble, but that will not always be the case. In your role as program director, it’s important to make sure your residents feel comfortable coming to you with concerns but also to look for hints in teacher evaluations and resident behaviours that suggest things are not okay. Regardless of how “approachable” you are, remember that a true power differential exists between you and your residents. This means you cannot assume they will always come to you when there is a problem.

Clues to problems in the learning environment can arise from a variety of sources, which are outlined in more detail in subsequent sections of this chapter. However, it is particularly important to watch for evidence that residents are burning out (exhibiting lack of empathy, caring or engagement in the program, with peers or with patients; requesting leaves of absence or transfers out of the program) or avoiding certain teachers or clinical experiences (a pattern of lower ratings than usual on teacher evaluations, residents never requesting certain preceptors, residents asking to switch weeks or shifts to work with different preceptors, a pattern of requests from residents to do clinical rotations at other sites or institutions).

Explore the issue when you receive complaints about preceptors

If you are a new program director, you may feel inclined to react immediately to resident concerns about a teacher’s behaviour. If there is a complaint about egregious behaviour, such as sexual harassment, racism or patient safety issues, this is absolutely the most appropriate action. You should begin by immediately contacting your postgraduate medical education office to ensure that you follow the correct policies for dealing with egregious issues. Make sure that you document the concerns in detail, in writing. Do not delay in proceeding as directed by your local policies, and enlist help from your chair if needed.

Fortunately, most teacher–learner conflicts do not stem from egregious behaviours. They are often more nuanced than a few lines on a teacher evaluation can capture. If you receive a concerning teacher evaluation, it is critical to meet with the resident in person to invite them to share the details and context of the experience. If others were present, it can be helpful to obtain their perspectives as well, if appropriate. Document the concerns.

Importantly, you must also have a conversation with the preceptor in question. You will have to balance the need to respect resident anonymity with the need to explore the situation with the preceptor to obtain their perspective. This process must include a transparent discussion with the resident to ensure that they understand that, depending on the specific issue, it may not be possible to maintain their anonymity if feedback is to be brought forward to the preceptor. If the issue is not terribly egregious, the resident may favour waiting until additional feedback to corroborate their concerns is collected from other individuals over time, in the interest of maintaining their anonymity. Regardless, a pattern of complaints about an individual preceptor will require you to give feedback to the preceptor, explore the issues with him or her (for example, is the preceptor well?) and make a plan to support the preceptor to make improvements if indicated and appropriate. If you are fairly junior in your department and the preceptor is senior to you, you may wish to enlist the help of the department chair or another senior educator in the group to support you in the discussion.

Influence the culture

The Merriam-Webster dictionary describes the culture of an organization as “the set of shared attitudes, values, goals, and practices that characterize an institution or organization.”12 In business, and in medicine, a variety of factors have been identified that contribute to a learning-oriented culture. These include openness, a spirit of inquiry, cooperation, empathy, self-reflection and systems thinking.13

How education is valued within your academic institution will probably play a role in defining how your residency education program is valued and prioritized within your department. Although it is impossible to change culture single-handedly, there are some practical approaches you can employ to make sure your residency training program is “on the radar” in your department and that your residents are valued team members in the context in which they train and work.

As program director, you are responsible not only for your residency program but also for a collection of smart young doctors who will bring a lot of value to your group. In exchange for the teaching they provide, the members of your group gain the opportunity to learn from residents (who often help attending physicians to keep up to date) and benefit from the service the residents provide. In many programs, residents’ service is a pivotal component of the department’s overall service delivery and would be sorely missed if withdrawn.

With these things in mind, each program director should have a seat at the key leadership tables in their department. In negotiating your role as program director, it is important to confirm with your department chair that you have their unwavering support in decisions you will have to make concerning the residency program. This means that when your attendings need to participate in training about how to evaluate entrustable professional activities, give feedback or question effectively, your chair will help you to mobilize them to participate. You may need to encourage your department’s leadership to articulate that residency education is a priority in your group, that teaching is taken seriously and that teaching evaluations are taken seriously. This messaging will influence your department’s culture if it comes from the top and will help to ensure that your residents feel a part of the team and feel supported by the attending physicians.14

The backing of local leadership is essential when these common issues arise in departments:

  • balancing service needs with educational requirements
  • dealing with resident shortages
  • getting buy-in from attending faculty members for new educational innovations such as competency-based medical education
  • finding physicians to help with accreditation preparation, resident selection, developing remediation and learning plans, and evaluating residents

With a voice at your department’s leadership table and support from your chair, you will be more able to successfully mitigate an “us versus them” culture when issues arise relating to the balance between on-call service and education. This will, in turn, reduce resentment between attending physicians and learners and avoid the propagation of disrespectful narratives that contribute to burnout and health issues.

Establish strong teacher–learner relationships

A key component of the constellation of social influences on learning, according to Bandura, is the model. Models are individuals from whom the learner derives new knowledge, skills and attitudes, both positive and negative.1 In the context of residency education, these may be attending physicians, senior residents, allied health professionals, nurses or near peers.

In postgraduate medical education the relationship between teacher and learner is pivotal in influencing residents’ behaviours. It has been suggested that there may be an educational alliance akin to the therapeutic alliance described in psychology. Telio and colleagues describe the educational alliance as being determined according to the perception of the learner. The alliance is formed when the learner believes that a teacher has a positive relationship with them, is interested in their learning, is clinically competent and is providing credible feedback because they observed the learner’s performance.8

When teacher–learner relationships are sound, learner performance is enhanced and burnout is decreased.10,15 How do you establish strong teacher–learner relationships in your program? First, make sure this is a priority in your own teaching. As program director, you will probably have more face-to-face time with the residents than anyone else in your department. Demonstrate your interest in your residents by getting to know them. Make it clear that you are there to support their learning and address their needs throughout their training, and offer an open-door policy to support them when they have questions, concerns or challenges. Recognize that for some racialized learners and those from other equity deserving groups, it will be important for you to check in regularly to gauge their sense of belonging in the program and to ask explicitly about experiences of discrimination in the learning environment.  You can also add value by facilitating connections between your residents and faculty with shared lived experience. Then, with the backing of your departmental leadership, ensure that there are rewards for the best teachers, that all department members have opportunities to enhance their teaching skills and that there is a clear process to help teachers who struggle. Most institutions have faculty development offices, which develop and deliver instructional skills workshops. Each institution will have policies on how best to manage struggling teachers.  When you have a teacher who is struggling, be sure to meet with them, offer support and ensure that they avail themselves of faculty development opportunities. You may need the department chair to ensure that this occurs.

Support your teachers

The quality of an educational environment’s teachers plays a key role in the perception that students form of that environment.14,16 Residents rate learning environments highly when they perceive that their teachers have excellent mentoring skills, provide timely and balanced feedback, are accessible when needed, assign appropriate tasks for the level of training and provide clear expectations.14 As program director, your role is to help your faculty be the best teachers and mentors that they can be. You can do this by providing them with relevant faculty development around teaching skills, providing feedback and coaching and setting expectations.  You can also do this by including specific faculty development and training in topics such anti-racism and cultural humility.

Review and update system supports

Finally, take a close look at the structures in place for your residents. There are multiple structural factors that can enhance the learning environment for your residents. Many of these are enshrined in the standards of accreditation (e.g., adequate call rooms). At the same time, there are structural factors that can contribute to resident harm and it is important to be aware of these as well. The absence of comprehensive and explicit anti-racism policies and the lack of safe and effective reporting mechanisms to address race-based harm are examples of structural factors known to promote resident unwellness.  However, there are initiatives you can implement to enhance the learning environment for your residents.

There are published instruments available to measure the learning environment in inpatient and ambulatory settings.14,16 Consider reviewing these to evaluate your residents’ learning environments. Structural elements to consider include providing learning objectives, allotting sufficient time to assess patients, ensuring there is time to eat and sleep, and providing access to computers, library resources and a place to store belongings.16 Residents should have work hours that reflect their contracted duties, structured or protected learning time and orientation documents for new rotations, and they must feel “physically safe” in the work environment.14

In summary, the learning environment is multi-faceted, and each aspect of the learning environment can foster or impede learning. As program director, you will play a key role in setting the tone, influencing the culture and mentoring both the residents and the teachers at your institution. Your personal commitment to the well-being and education of residents will make an important contribution to the residents’ experience, and it will provide a model for other teachers in your group. Your close attention to the well-being of your residents will be paramount in ensuring that they successfully complete their training and leave residency well prepared for independent practice.

References

  1. Bandura A. Social learning theory. Upper Saddle River (NJ): Prentice Hall; 1977.
  2. Ames C, Archer J. Achievement goals in the classroom: students’ learning strategies and motivation processes. J Educ Psych. 1988;80:260–7.
  3. Ajzen I. The theory of planned behaviour. Organ Behav Hum Decis Process. 1991;50(2):179–211.
  4. Hodges BD. A tea-steeping or i-Doc model for medical education? Acad Med. 2010;85(9 Suppl):S34–44.
  5. Frank JR, Snell LS, Ten Cate O, Holmboe ES, Carraccio C, Swing SR, et al. Competency-based medical education: theory to practice. Med Teach. 2010;32:638–45.
  6. Bing-You RG, Trowbridge RL. Why medical educators may be failing at feedback. JAMA. 2009;302(12):1330–1.
  7. Watling C. Cognition, culture, and credibility: deconstructing feedback in medical education. Perspect Med Educ. 2014;3:124–8.
  8. Telio S, Ajjawi R, Regehr G. The “educational alliance” as a framework for reconceptualizing feedback in medical education. Acad Med 2015;90(5):609–14.
  9. Genn JM. AMEE Medical Education Guide No. 23 (Part 1): Curriculum, environment, climate, quality and change in medical education–a unifying perspective. Med Teach. 2009;23(4):337–44.
  10. Hu YY, Ellis RJ, Hewitt B, Yang AD, Cheung EO, Moskowitz JT, et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med. 2019;381:1741–52.
  11. Centre C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161–66.
  12. Merriam-Webster Dictionary. Definition of culture. Available from: merriam-webster.com/dictionary/culture (accessed 20 Feb. 2020).
  13. Hoff TJ, Pohl H, Bartfield J. Creating a learning environment to produce competent residents: the roles of culture and context. Acad Med 2004;79:532–40.
  14. Roff S, McAleer S, Skinner A. Development and validation of an instrument to measure the postgraduate clinical learning and teaching educational environment for hospital-based junior doctors in the UK. Med Teach. 2005;27(4):326–31.
  15. Daugherty SR, Baldwin DC, Rowley BD. Learning, satisfaction, and mistreatment during medical internship. A national survey of working conditions. JAMA. 1998;279(15):1194–99.
  16. Riquelme A, Padilla O, Herrera C, Olivos T, Roman JA, Safatis A, et al. Development of ACLEEM questionnaire, an instrument measuring residents’ educational environment in postgraduate ambulatory setting. Med Teach. 2013;35(1):e861-6.