Abstract social support (P-value=0.013) and the overall score

Abstract

Background:

The Educational Environment has a large influence on the success of medical
education and overall outcome. There is little data on how the trainee’s (residents) perceive the Educational
Environment in the hospital and the process of obtaining their skills. Evaluating
and measuring the residents’ perception of educational environment is of
crucial role to Educational process improvement and could be used as a guiding
tool in policy making. Hospitals that
provide Urology program for postgraduates might be interested in the results to
know and acknowledge their strengths and improve their weakness points in order to
develop and further enhance their education and training outcomes.

Aim:

To evaluate the hospital teaching environment for residents of
urology program Using PHEEM tool

Methods:

This Cross-sectional study was conducted on 57 urology residents
using PHEEM questionnaire; the study was conducted between July and August 2017. The
data obtained were analyzed by using SPSS
program, and the result was interpreted according to the questionnaire
instruction.

Results:

The mean ± SD of perception of role autonomy was 33.14 ±6.76, for perception of teaching was 38.5 ±8.14, for perception of social support was 26.56±5.88 and
the mean ± SD of overall score was 98.21±18.34. The overall score indicated that
there was more positive than negative but room for improvements. Residency
level significantly affected the perception
of role autonomy (P-value=0.012), the overall
score (P-value=0.024). The region was significantly affected perception of role autonomy (P-value=0.002), perception of social support (P-value=0.013)
and the overall score (P-value=0.007).

Conclusion:

There was a good educational
environment for the urology program, but with the need for further improvement.

Keywords: PHEEM, Urology program, Educational Environment.

 

 

Introduction:

Most of the medical
residents’ training is performed through hospital programs 1. In residency programs, educational and
academic environments are provided to
residents which aims to specialized
clinical training 2. Also the
residents learn professional attitudes and behavior 3,4. The
effectiveness of a learning program can be measured by the educational
environment. The quality of learning educational environment is critical
for determining the level of learner’s training 5. The hospital
environment of clinical learning is a significant and persuasive factor of
work-based learning 5, Maudsley considered that learning
environment was an essential component of medical education 6. In
developed countries, the work environment of the residency program and its effect on residents got an interest in
medical academia 7. It was found
that the development of professional skills of medical practitioners largely
depends on the attributes of the environment in which they work 8. The
good clinical, educational environment
activates deep learning, encourages professional intelligence, ensures that
both the learning and teaching processes are related to the patients in real life, makes post-graduate residents to
be actively involved and have an observed contribution 5. However, the
negative or bad clinical, educational
environment obstructs the process of learning, fewer
achievements of residents and results in a poor
outcome, this negative environment also can lead to exhaustion, burnout
and fatigue of post graduated residents which fail
in training 5. Postgraduate Hospital
Educational Environment Measure questionnaire (PHEEM) is a questionnaire of
40-questions to assesses metrics of the level of autonomy, quality of teaching
and social support during the training period in the hospitals to identify
weakness and strength of a definite
educational environment 1. PHEEM is a validated reli­able instrument to assesses strengths and
weaknesses of a certain educational environment as well as the quality assur­ance
process 1,9. In Saudi Arabia, The urology residency training is
a 5- year structured program which is supervised by the Saudi Commission for
Health Specialties (SCFHS), after completing the residency period, the
residents receive certification as a specialist 10.
 The Educational Environment has a large
influence on the success of medical education and overall outcome. However,
there is little data on how the trainee’s
(residents) perceive the educational environment and the process of obtaining
their skills in the hospitals that provide the program. We aimed to evaluate
the educational-environment perceptions of Saudi urology residents’ using validated
questionnaire for this purpose.

 

Subjects and methods

Subjects and study design:

This study is a Cross-sectional study which was conducted on 57
urology residents using a questionnaire which was distributed both
electronically and by hard copy to urology residents of all residency levels through
all hospitals of Saudi Arabia between July and August 2017.

The questionnaire:

The questionnaire used is The Postgraduate Hospital Educational
Environment Measure (PHEEM), it is a self-administered 40 item questionnaire. The
questionnaire contains demographic
questions, and The PHEEM part contains 40 statements covering a range of
topics directly relevant to the educational climate. The PHEEM is divided into 3 parts : the first part includes 14 items to
measure the levels of perception of autonomy, the second assesses the perception
of quality of teaching which has a subscale of 15 items and the third part to
assesses the perception of  social
support which has a subscale of 11 items during the postgraduate hospital
training in Educational Institutes. Respondents were asked to choose
from a five-point scale which ranges from
0-4 as follows: (4) strongly agree, (3) agree, (2) uncertain, (1) disagree, (0) strongly disagree. An item with a mean score of
3.5 or more is a positive item, an item of 2 or less mean score needs further
exploring as it indicates an area of a
problem, items with a mean score 2-3 are
areas to enhance.  There are four items
in the questionnaire with negative statements which are scored in reverse order (items 7,8,11 and 13).

An overall score of:

0-40 indicates a very poor Educational Environment

41-80 indicates plenty of problems

81-120 indicates more positive than negative, but there’s room for improvement

121-160 indicates an excellent Educational Environment

 

Statistical analysis:

Data were analyzed using SPSS software version 16, the simple descriptive analysis in the form of
means and standard deviations were calculated for numerical data. Qualitative
data were described using numbers and
percent distribution. quantitative variables are
tested for normality. The mean level of total scores and subscales were compared
between two group using independent t-test
and ANOVA test between more than two groups.
A significant level of less than 0.05 was
considered.

Results:

The current study was performed
on 57 residents, the large majority of
them were males 54(94.7%), while 3 (5.3%) only were females. Residents from
level 3 were the most dominant participants 16(28.1%) followed by those from
level 4 who were 15 (26.3%), then
residents from levels 2,1 and 5 representing 11(19.3%), 10(17.5%) and 5 (8.8%)
respectively. There were 32(56.1%) residents from the central region, 4(7%) were from the western
region, 16 (28.1%) and 5 (8.8%) were from eastern and northern regions respectively. Most of the participants were from military hospitals
28(49.1%), while there were 21(36.8%) from MOH and 8(14%) from academic hospitals. The range of overall score obtained was 50 to 143 with a mean ± SD of
98.21±18.34, the range of perception of autonomy role was 15 to 47 with a mean
± SD of 33.14 ±6.76, while the range of perception of teaching was 19 to 57
with a mean± SD of 38.5 ±8.14 and the range of perception of social support was
10 to 39 with a mean ±SD of 26.56±5.88, the means of each subscale and overall
score are shown in figure1.

Fig1: The mean
of score of each scale and overall score

The interpretation of overall
score indicated that there were 11(19.3%)
saw that there were plenty of problems, 5 (8.8%) reported that there was an
excellent educational environment, while the large
majority 41(71.9%) reported that there
was positive than negative but room for improvements.
Regarding the perception of autonomy
role, there were 14 (24.6%) had a negative view
of one’s role,
38(66.7%) reported the more positive perception
of ones’ job and 5 (8.8%) only reported the excellent
perception of one’s job.
Regarding perception of teaching, 10
(17.5%) reported that they were in need
of some retraining, 36 (63.2%) thought that they were moving in the right
direction and 11 (19.3%) thought that the
teachers were model teachers. The score of perceptions
of social support part showed that 1 (1.8%) and 15 (26.3%) thought that the
social support did not exist and the place was not pleasant respectively, while
36(61.4%) and 6(10.5%) reported that there were more pros than cons and the
supportive environment was good respectively, table1.

Table1: Interoperation of overall scores and scores of each part

Interpretation of scores

N

%

Overall score perception score

Plenty of
problems

11

19.3

More positive than negative but room for improvement

41

71.9

Excellent Educational
Environment

5

8.8

Perception of
Autonomy role

A negative view of one’s role

14

24.6

A more
positive perception of one’s job

38

66.7

Excellent
perception of one’s job

5

8.8

Perceptions of teaching

In need of
some retraining

10

17.5

Moving in the
right direction

36

63.2

Model
teachers

11

19.3

Perceptions of social support

 Non-existent

1

1.8

Not a
pleasant place

15

26.3

More pros
than cons

35

61.4

A good
supportive environment

6

10.5

 

The correlation between the mean of scores and different variables is shown in table2. Regarding gender, there
were no significant differences in the overall scores
and the scores of each subscale. By assessing the residency level on the scores, significant differences were found in the perception of role autonomy (P*value=0.012), where residents in
residency level 4-5 had higher mean score than those in residency level 1-3,
and residents in level 4-5 had higher mean overall score than those in level 1-3 (P-value=0.024). Regarding region,
significances were found in Perception of role autonomy (P-value=0.002), social
support (P-value=0.013) and the overall score (P-value=0.007), with higher in
the mean score in participants from the eastern
region. The hospital had no significant effect on the overall score
or the scores of each subscale.   

Table2: correlation
between the mean of scores regarding different variables

Variables

Perceptions of role autonomy

Perceptions of teaching

Perceptions of social support

the overall score

Gender
Male
Female
P-value

 
33.35±6.87
29.33±2.51
0.3

 
38.61±8.26
36.67±6.5
0.6

 
26.81±5.92
22±2.64
0.1

 
98.77±16.65
88±6.08
0.3

Residency
level
1-3
4-5
P-value

 
31.51±6.92
36.15±5.43
0.012*

 
37±8.37
41.3±7.06
0.056

 
25.7±6.38
28.15±4.56
0.1

 
94.21±19.15
105.6±14.42
0.024*

Region
Central
Western
Eastern
P-value

 
33.62±5.64
26.25±5.05
36±5.86
0.002*

 
39.53±7.21
36.5±9.46
39.37±8.39
0.1

 
26.97±5.66
22.75±6.23
28.75±4.52
0.013*

 
100.12±15.78
88.5±17.52
104.12±16.93
0.007*

Hospital
MOH
Academia
Military
P-value

 
32.52±6.57
35.75±5.36
32.85±7.28
0.5

 
36.28±7.93
40.62±6.23
39.57±8.62
0.2

 
24.95±5.23
28±3.89
27.35±6.65
0.2

 
93.76±16.77
104.38±13.93
99.78±20.24
0.3

*P-value; significant

Discussion:

It was reported by The World
Federation for Medical Education (WFME) that the evaluation of learning
environment is one of the main goals for “the conduction of the evaluation of
medical education program”11.  PHEEM
can be used to identify the weakness and strengths of the residency medical
program 1. In the present study the
mean of overall score was 98.21 which indicated to more positive than negative
but there’s room for improvement, also there were 71.9% participants whose
scores met this criterion, the mean score of perception of role autonomy was
33.14 indicating a more positive perception of one’s job, with a percent
66.7% of participants, the mean score was 38.5 for perception of teaching which indicated
moving in the right direction with a percent of 63.2% of participants and 26.56
for perception of social support which indicated more pros than cons with a
percent of residents equal 61.4%. The previous
finding should be taken into account by curriculum planners to improve the
educational program. A total PHEEM score was 77.7 from urology residency
program in Saudi Arabia as reported from a previous
study which indicated plenty of problems 10, however,
our results showed that there was an improvement in the urology program and the
score was increased in our study than the
previous Saudi study. The mean score of the role
of autonomy indicated nega­tive view of one’s role (26.2), of teaching it
indicted teachers, are in need of some
retrain­ing (29.7), and for the social support,
it indicated to the unpleasant environment
(21.9) 10.  Another study
from Saudi Arabia showed a much lower PHEEM score of 67.1 12. The
scores of subscales were 26.18, 29.7 and 21.9 for perceptions of role autonomy,
teaching, and social support respectively; these scores are much lower than ours. A
study from Pakistan 5 reported that the overall PHEEM score was 103.29
± 12.75 which showed that post graduate
participants perceived the training environment as more positive with still
room for improvement, this was in agreement with our findings. Also, the previous study showed that the
subscale perception of role autonomy score was 36.11 indicating positive observation of their role. The
perception of teaching score was 39.02 indicating moving on the right path, while the perception of
social support score was 28.16 5. These previous findings were similar
to ours. Mahendran et al. 13
evaluated PG Psychiatry residency training program in Singapore, and they found that PHEEM total score was 106,
with scores of subscale; perception of role autonomy, teaching, and social support score were 36.20, 44.85 and
25.85 respectively. BuAli et al. 14
in Saudi Arabia evaluated pediatric PG residency learning environment of 6
teaching hospitals, and they found that
The overall PHEEM score was 100.19, with scores of 34.9, 38.89 and 26.38 for
the subscales role autonomy, teaching and social support respectively, these
findings are in agreement with ours. A study from Australian rural hospital
showed higher scores than ours regarding overall scores and scores of each
subscale, where total PHEEM score was 117 from medical and surgery residents,
with sub scale scores of 45 for role
autonomy, 39 for teaching and 33 for social support 15. Our results
seem to be higher than that previously reported in several Saudi studies. Al-Marshad
and Alotaibi16  evaluated the clinical, educational environment at King Fahad
Hospital of Dammam University, and they
demonstrated that the overall score was 82.63. Also
a study from University Teaching Hospital in Ireland reported a score of 82.88 17.
In this study, gender did not affect the
mean overall score or the mean score of each subscale,
the mean of overall scores for males and females indicated more positive than
negative but room for improvement. In the perception of role autonomy subscale, mean scores of males and
females indicated a more positive perception of ones’s job. In the perception of teaching subscale,
the mean score of males and females indicated moving in the right direction.
Regarding the perception of social
support, the mean score of males indicated more pros than cons, while for a female it indicated a not pleasant place,
however with no significance difference (P-value=0.1). In one study 18
it was found that gender significantly affected the three subscales and the
overall score. The current
study showed that residency level significantly affected two subscales mean
scores; perception of role autonomy (P-value=0.012) and the overall mean score
(P-value=0.024) with the higher mean score
for participants in the residency level of 4-5. The overall score of residents
of level 1-3 and 4-5 indicated more positive than negative but room for improvement
and regarding the perception of role autonomy subscale the mean score indicated
to a more positive perception of ones’s job. In a previous Saudi study 10 it was reported that there
was no effect of residency stage program on the educational environment,
another study reported similar results to the previous Saudi results 16.
Another study 18 showed that there was no significant difference
between different residency level regarding the three subscales and the overall
score. The present study revealed that the mean score of participants from
eastern region was the highest among all participants from other regions, with
a significant difference in the overall score (P-value=0.007) as well as role
autonomy (P-value=0.002) and social support subscales (P-value=0.013). Regarding
role autonomy subscale, the mean score of participants from the western region
indicated a negative view of one’s role, while the mean score of residents from
central and eastern regions indicated a more positive perception of one’s job. The
mean score of western region the social support subscale indicated a not
pleasant place, whereas for eastern and central regions the mean score
indicated more pros than cons. The mean overall score indicated more positive
than negative but room for improvement. In contrary to our findings, a study
from Saudi Arabia showed that training region had no effect on resi­dents’
perception of their educational environment 10, however Australian
study 15 reported that rural regions performed better than urban
regions on the three subscales. In this study, the hospital from which
residents participated had no significant effect on the score of each subscale or
on the overall score. Our findings were contrasted with previous Saudi results
where it was demonstrated that different main sectors affected significantly on
the total score and the teaching subscale 10.  

 

Conclusion:

In the present study, the
educational environment was good, however
further improvements are needed. The residency level and region significantly
affected the overall score which indicated that these two variables
significantly affected the educational
environment. Further studies are recommended with large sample size and
several regions.