Assessing the Clinical Learning Environment in an Institution in the United Arab Emirates: The Resident Perspective
ABSTRACT
Background
A new accreditation model in the United States has increased focus on the clinical learning environment (CLE). There is limited research on trainee perceptions of the CLE in international settings.
Objective
We surveyed residents to obtain their perspective on the CLE at 1 sponsoring institution in the United Arab Emirates (UAE).
Methods
We surveyed residents at Tawam Hospital, UAE, a sponsoring institution with 142 trainees, on their perspectives in the 6 focal areas of the US Clinical Learning Environment Review (CLER) to gather baseline information. We administered a 26-item questionnaire to residents through an audience response system in November 2018.
Results
Of 100 residents in postgraduate year 2 and above, 72 (72%) responded. The perspective of the majority of respondents was favorable in the areas of reporting patient safety incidents, engaging in quality improvement activities, using a standardized form for care transition, and using professional guidelines for electronic health record documentation. In contrast, only half of the respondents perceived there is honesty in the reporting of duty hours, and only 36% felt the organization supported fatigue management. Other areas for improvement included residents' understanding of the concept of health disparities and activities to address health disparities.
Conclusions
Our findings suggest that in key focal areas related to patient safety, health care quality, care transitions, and professionalism, UAE residents have similar perceptions of their CLE as US trainees. Opportunities for improvement include duty hour reporting, fatigue mitigation, and addressing health disparities.
Introduction
In 2012, the Accreditation Council for Graduate Medical Education (ACGME) introduced the Clinical Learning Environment Review (CLER) as an innovative process to improve patient safety and health care quality in institutional settings for graduate medical education (GME). At the core of CLER is formative feedback in 6 focal areas: (1) patient safety, (2) health care quality, (3) care transitions, (4) supervision, (5) fatigue management, mitigation, and duty hours, and (6) professionalism.1
The first CLER program report in 2016 highlighted variability in resident engagement to improve patient safety, health care quality, and other focus areas.2 A second report published in 2018 observed CLER contributed to improvement in focal areas such as patient safety, health care quality, and supervision, although variability in resident engagement with the clinical learning environment (CLE) persisted.3–5
Methods
Setting
Tawam Hospital is a 469-bed tertiary care teaching hospital in Abu Dhabi. It serves as the sponsoring institution for ACGME-International accredited programs in anesthesiology, emergency medicine, internal medicine, otolaryngology, surgery, pediatrics, and a neonatology fellowship, with a total of 142 trainees in academic year 2018–2019. GME leadership at Tawam Hospital has integrated the training programs with hospital operations to improve performance in the CLER focus areas. This includes an annual orientation on CLER focus areas attended by executive leadership. The designated institutional official (DIO) attends the monthly hospital leadership meetings, and hospital executives attend the monthly meeting of the Graduate Medical Education Committee (GMEC). Tawam Hospital's GME programs offer education on the 6 CLER focal areas, and the resident council meets as needed with the DIO and hospital leadership to discuss residency issues.
The GME vision at Tawam Hospital is excellence in medical education. A key area is the CLE, yet we lacked data on residents' perceptions in the 6 CLER areas. We surveyed residents to deepen our understanding of the CLE at Tawam Hospital, generate baseline data for improvement efforts, and compare our data to national CLE data from the United States.
Survey Development
A literature search by the authors yielded a 26-item questionnaire on the 6 CLE focal areas used at the University of Colorado.6,7 The questions were addressed specifically to residents, and the responses used a Likert scale (1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree). The questions were reviewed by a focus group consisting of program directors (other than the authors) and core faculty for clarity and meeting objectives, and we subsequently pilot tested the survey on 5 residents. The reviews assessed survey length, readability, comprehension, completion time, layout, and ease of administration. These reviews offered no suggestions for improvements, and we used the University of Colorado questionnaire without any modifications.
Sample
We used random sampling and Slovin's formula to calculate the sample size.8 Participation of 80 residents in the survey would yield a confidence interval of 95% and a margin of error of 5%; participation by 74 would yield a confidence interval of 90% and a margin of error of 10%.8
We targeted residents in the postgraduate year 2 (PGY-2) and beyond. We excluded PGY-1 residents and trainees who did not provide consent.
We administered the survey using an audience response system accessible via handheld devices (Mentimeter) during classroom training sessions in November 2018. Residents were given a 10-minute presentation on the background and goals of the CLER program. Residents were informed that the survey was part of a research study.
The study was approved by the Tawam Human Research Ethics Committee. Informed consent was obtained before the survey administration.
Data Analysis
Data were analyzed using SPSS Statistics 22 (IBM Corp, Armonk, NY). We consolidated the data, assigning strongly agree and agree responses a numerical value of 4, strongly disagree and disagree a numerical value of 2, and neutral a value of 3.
Results
Of 100 eligible residents, 72 (72%) took part in the survey. Responses by specialty are shown in the figure. The sample size's confidence level was nearing 90% with an acceptable margin of error.
Citation: Journal of Graduate Medical Education 11, 4s; 10.4300/JGME-D-18-01028
Cronbach's alpha for individual questions ranged from 0.893 to 0.905, and the overall Cronbach's alpha for the 26-item survey was high at 0.898.9,10
Participant responses compared with CLER findings from 201611 and 201812 are shown in the table. This showed that for some dimensions of patient safety, the percentage of residents with a positive perception of these attributes of their learning environment was comparable to the US CLER data. In our survey, 68% of the residents reported they were involved in quality improvement (QI) activities and interprofessional training to optimize care transitions. A CLER focal area that presented an opportunity for improvement was support for reporting safety events at clinical sites and disclosure of safety incidents to patients. Several areas within the QI domain showed lower percentages of positive responses than the US comparison data, including resident awareness of clinical site priorities for QI, resident knowledge about health disparities, and resident engagement to address health disparities.
Most residents reported they use direct communication in developing patient care plans among primary and consulting teams (85%, 61 of 72), use standardized verbal communication process for patient transfers (81%, 58 of 72), and that the transfer of patients between services involve interprofessional staff members (79%, 57 of 72), yet only 50% (36 of 72) reported they were aware of clinical sites policies and procedures for care transition. Fifty-eight percent of residents (42 of 72) responded that the clinical site provides a supportive culture for requesting assistance, and 22% (16 of 72) indicated supervision was inadequate, comparable to data from the national CLER samples for 2016 and 2018.11,12 Duty hour reporting and creating a culture that supports fatigue management showed lower percentage of positive findings compared to the US CLER data. Slightly more than half of respondents indicated Tawam Hospital provides an environment of professionalism, compared to nearly all US residents.5
Discussion
Our results showed both positive attributes and opportunities for improvement in the 6 CLER focal areas (see the box). The data identify aspects of residency and fellowship training in which our institution is achieving success, including educating and encouraging the participation of trainees in patient safety, health care quality, care transitions, and professionalism. Opportunities for improvement and selected action steps to be taken are summarized below.
Patient Safety
Similar to progress in patient safety incident reporting in the United States,1,2,5 the next step at our institution is to engage more residents to report safety incidents and participate in the investigation as opportunities for experiential learning.7 One example is involving residents in the hospital's Comprehensive Unit Safety Program where safety incidents and other systems challenges are discussed in detail and action plans are developed.
Health Care Quality
One potential reason for the residents' poor knowledge about QI priorities and health disparities is that our residents are not well represented on hospital-wide QI committees. To address this, the QI curriculum needs to be developed collaboratively by the quality department, GME, and hospital staff, and residents should be actively involved in QI meetings in which systems-based challenges and approaches to address them are discussed.7
Fatigue Management, Mitigation, and Duty Hours
Our CLE places a high value on ensuring adherence to duty hour limits, availability of on-call rooms, and education on fatigue management. Despite this, some of the residents' perception was that duty hour reporting is not accurate and the CLE does not support fatigue management. To address this disconnect between policies and procedures and resident perceptions, GME leadership needs to develop more systematic strategies and solutions that focused on prevention, recognition, and effective mitigation of fatigue.
Our study has limitations. First, we did not use open-ended questions, which might have offered deeper insight into opportunities and challenges in the local CLE. Surveying the executive leadership, GMEC, and program faculty would have provided a more complete picture of the CLE.
Baseline data, challenges, and opportunities will be communicated to the institutional leadership through the GME. We plan to administer the survey to the executive leadership, QI teams, program faculty, and members of the GMEC to offer a comprehensive picture of our CLE, including the engagement of faculty and the GMEC. The intent is to promote collaboration between GME and hospital leadership in addressing challenges and providing experiential learning opportunities for our trainees.
Conclusion
A survey of the 6 CLER focal areas at 1 UAE institution showed the institution is successful in educating and encouraging the participation of residents and fellows in areas of patient safety, health care quality, care transitions, and professionalism. For some dimensions of the CLE, our findings are comparable to national US CLER data, while for others, it highlights the newer GME infrastructure in the UAE, with areas for future growth and improvement.
Percentage of Residents Surveyed by Specialty
Author Notes
Funding: The authors report no external funding source for this study.
Conflict of interest: The authors declare they have no competing interests.
The authors would like to thank Ali Alaauddin, MBBS, Shamma Al Shamisi, and Aysha Al Jaberi, Department of Academic Affairs, Tawam Hospital.
