AbstractBackground:The Educational Environment has a large influence on the success of medicaleducation and overall outcome. There is little data on how the trainee’s (residents) perceive the EducationalEnvironment in the hospital and the process of obtaining their skills. Evaluatingand measuring the residents’ perception of educational environment is ofcrucial role to Educational process improvement and could be used as a guidingtool in policy making. Hospitals thatprovide Urology program for postgraduates might be interested in the results toknow and acknowledge their strengths and improve their weakness points in order todevelop and further enhance their education and training outcomes.
Aim:To evaluate the hospital teaching environment for residents ofurology program Using PHEEM toolMethods:This Cross-sectional study was conducted on 57 urology residentsusing PHEEM questionnaire; the study was conducted between July and August 2017. Thedata obtained were analyzed by using SPSSprogram, and the result was interpreted according to the questionnaireinstruction.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 andthe mean ± SD of overall score was 98.21±18.34.
The overall score indicated thatthere was more positive than negative but room for improvements. Residencylevel significantly affected the perceptionof role autonomy (P-value=0.012), the overallscore (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 educationalenvironment for the urology program, but with the need for further improvement.Keywords: PHEEM, Urology program, Educational Environment. Introduction:Most of the medicalresidents’ training is performed through hospital programs 1.
In residency programs, educational andacademic environments are provided toresidents which aims to specializedclinical training 2. Also theresidents learn professional attitudes and behavior 3,4. Theeffectiveness of a learning program can be measured by the educationalenvironment. The quality of learning educational environment is criticalfor determining the level of learner’s training 5.
The hospitalenvironment of clinical learning is a significant and persuasive factor ofwork-based learning 5, Maudsley considered that learningenvironment was an essential component of medical education 6. Indeveloped countries, the work environment of the residency program and its effect on residents got an interest inmedical academia 7. It was foundthat the development of professional skills of medical practitioners largelydepends on the attributes of the environment in which they work 8. Thegood clinical, educational environmentactivates deep learning, encourages professional intelligence, ensures thatboth the learning and teaching processes are related to the patients in real life, makes post-graduate residents tobe actively involved and have an observed contribution 5. However, thenegative or bad clinical, educationalenvironment obstructs the process of learning, fewerachievements of residents and results in a pooroutcome, this negative environment also can lead to exhaustion, burnoutand fatigue of post graduated residents which failin training 5. Postgraduate HospitalEducational Environment Measure questionnaire (PHEEM) is a questionnaire of40-questions to assesses metrics of the level of autonomy, quality of teachingand social support during the training period in the hospitals to identifyweakness and strength of a definiteeducational environment 1. PHEEM is a validated reliable instrument to assesses strengths andweaknesses of a certain educational environment as well as the quality assuranceprocess 1,9.
In Saudi Arabia, The urology residency training isa 5- year structured program which is supervised by the Saudi Commission forHealth Specialties (SCFHS), after completing the residency period, theresidents receive certification as a specialist 10. The Educational Environment has a largeinfluence 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 obtainingtheir skills in the hospitals that provide the program. We aimed to evaluatethe educational-environment perceptions of Saudi urology residents’ using validatedquestionnaire for this purpose. Subjects and methodsSubjects and study design:This study is a Cross-sectional study which was conducted on 57urology residents using a questionnaire which was distributed bothelectronically and by hard copy to urology residents of all residency levels throughall hospitals of Saudi Arabia between July and August 2017.The questionnaire:The questionnaire used is The Postgraduate Hospital EducationalEnvironment Measure (PHEEM), it is a self-administered 40 item questionnaire.
Thequestionnaire contains demographicquestions, and The PHEEM part contains 40 statements covering a range oftopics directly relevant to the educational climate. The PHEEM is divided into 3 parts : the first part includes 14 items tomeasure the levels of perception of autonomy, the second assesses the perceptionof quality of teaching which has a subscale of 15 items and the third part toassesses the perception of socialsupport which has a subscale of 11 items during the postgraduate hospitaltraining in Educational Institutes. Respondents were asked to choosefrom a five-point scale which ranges from0-4 as follows: (4) strongly agree, (3) agree, (2) uncertain, (1) disagree, (0) strongly disagree. An item with a mean score of3.
5 or more is a positive item, an item of 2 or less mean score needs furtherexploring as it indicates an area of aproblem, items with a mean score 2-3 areareas to enhance. There are four itemsin 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 ofmeans and standard deviations were calculated for numerical data. Qualitativedata were described using numbers andpercent distribution.
quantitative variables aretested for normality. The mean level of total scores and subscales were comparedbetween two group using independent t-testand ANOVA test between more than two groups.A significant level of less than 0.05 wasconsidered.Results:The current study was performedon 57 residents, the large majority ofthem were males 54(94.7%), while 3 (5.
3%) only were females. Residents fromlevel 3 were the most dominant participants 16(28.1%) followed by those fromlevel 4 who were 15 (26.3%), thenresidents 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 westernregion, 16 (28.1%) and 5 (8.8%) were from eastern and northern regions respectively. Most of the participants were from military hospitals28(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 of98.21±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 57with a mean± SD of 38.
5 ±8.14 and the range of perception of social support was10 to 39 with a mean ±SD of 26.56±5.88, the means of each subscale and overallscore are shown in figure1.Fig1: The meanof score of each scale and overall score The interpretation of overallscore indicated that there were 11(19.
3%)saw that there were plenty of problems, 5 (8.8%) reported that there was anexcellent educational environment, while the largemajority 41(71.9%) reported that therewas positive than negative but room for improvements.Regarding the perception of autonomyrole, there were 14 (24.6%) had a negative viewof one’s role,38(66.7%) reported the more positive perceptionof ones’ job and 5 (8.8%) only reported the excellentperception of one’s job.
Regarding perception of teaching, 10(17.5%) reported that they were in needof some retraining, 36 (63.2%) thought that they were moving in the rightdirection and 11 (19.3%) thought that theteachers were model teachers. The score of perceptionsof social support part showed that 1 (1.8%) and 15 (26.
3%) thought that thesocial support did not exist and the place was not pleasant respectively, while36(61.4%) and 6(10.5%) reported that there were more pros than cons and thesupportive 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, therewere no significant differences in the overall scoresand 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 inresidency 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), socialsupport (P-value=0.013) and the overall score (P-value=0.007), with higher inthe mean score in participants from the easternregion. The hospital had no significant effect on the overall scoreor the scores of each subscale.
Table2: correlationbetween 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; significantDiscussion:It was reported by The WorldFederation for Medical Education (WFME) that the evaluation of learningenvironment is one of the main goals for “the conduction of the evaluation ofmedical education program”11. PHEEMcan be used to identify the weakness and strengths of the residency medicalprogram 1. In the present study themean of overall score was 98.21 which indicated to more positive than negativebut there’s room for improvement, also there were 71.
9% participants whosescores met this criterion, the mean score of perception of role autonomy was33.14 indicating a more positive perception of one’s job, with a percent66.7% of participants, the mean score was 38.5 for perception of teaching which indicatedmoving in the right direction with a percent of 63.2% of participants and 26.56for perception of social support which indicated more pros than cons with apercent of residents equal 61.4%.
The previousfinding should be taken into account by curriculum planners to improve theeducational program. A total PHEEM score was 77.7 from urology residencyprogram in Saudi Arabia as reported from a previousstudy which indicated plenty of problems 10, however,our results showed that there was an improvement in the urology program and thescore was increased in our study than theprevious Saudi study. The mean score of the roleof autonomy indicated negative view of one’s role (26.2), of teaching itindicted teachers, are in need of someretraining (29.7), and for the social support,it indicated to the unpleasant environment(21.
9) 10. Another studyfrom Saudi Arabia showed a much lower PHEEM score of 67.1 12. Thescores 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. Astudy from Pakistan 5 reported that the overall PHEEM score was 103.29± 12.75 which showed that post graduateparticipants perceived the training environment as more positive with stillroom for improvement, this was in agreement with our findings. Also, the previous study showed that thesubscale perception of role autonomy score was 36.
11 indicating positive observation of their role. Theperception of teaching score was 39.02 indicating moving on the right path, while the perception ofsocial support score was 28.
16 5. These previous findings were similarto ours. Mahendran et al. 13evaluated 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 and25.85 respectively.
BuAli et al. 14in Saudi Arabia evaluated pediatric PG residency learning environment of 6teaching hospitals, and they found thatThe overall PHEEM score was 100.19, with scores of 34.9, 38.89 and 26.
38 forthe subscales role autonomy, teaching and social support respectively, thesefindings are in agreement with ours. A study from Australian rural hospitalshowed higher scores than ours regarding overall scores and scores of eachsubscale, where total PHEEM score was 117 from medical and surgery residents,with sub scale scores of 45 for roleautonomy, 39 for teaching and 33 for social support 15. Our resultsseem to be higher than that previously reported in several Saudi studies. Al-Marshadand Alotaibi16 evaluated the clinical, educational environment at King FahadHospital of Dammam University, and theydemonstrated that the overall score was 82.63. Alsoa study from University Teaching Hospital in Ireland reported a score of 82.
88 17.In this study, gender did not affect themean overall score or the mean score of each subscale,the mean of overall scores for males and females indicated more positive thannegative but room for improvement. In the perception of role autonomy subscale, mean scores of males andfemales 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 socialsupport, 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 18it was found that gender significantly affected the three subscales and theoverall score. The currentstudy showed that residency level significantly affected two subscales meanscores; perception of role autonomy (P-value=0.
012) and the overall mean score(P-value=0.024) with the higher mean scorefor participants in the residency level of 4-5. The overall score of residentsof level 1-3 and 4-5 indicated more positive than negative but room for improvementand regarding the perception of role autonomy subscale the mean score indicatedto a more positive perception of ones’s job. In a previous Saudi study 10 it was reported that therewas 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 differencebetween different residency level regarding the three subscales and the overallscore.
The present study revealed that the mean score of participants fromeastern region was the highest among all participants from other regions, witha significant difference in the overall score (P-value=0.007) as well as roleautonomy (P-value=0.002) and social support subscales (P-value=0.013). Regardingrole autonomy subscale, the mean score of participants from the western regionindicated a negative view of one’s role, while the mean score of residents fromcentral and eastern regions indicated a more positive perception of one’s job. Themean score of western region the social support subscale indicated a notpleasant place, whereas for eastern and central regions the mean scoreindicated more pros than cons. The mean overall score indicated more positivethan negative but room for improvement.
In contrary to our findings, a studyfrom Saudi Arabia showed that training region had no effect on residents’perception of their educational environment 10, however Australianstudy 15 reported that rural regions performed better than urbanregions on the three subscales. In this study, the hospital from whichresidents participated had no significant effect on the score of each subscale oron the overall score. Our findings were contrasted with previous Saudi resultswhere it was demonstrated that different main sectors affected significantly onthe total score and the teaching subscale 10. Conclusion:In the present study, theeducational environment was good, howeverfurther improvements are needed. The residency level and region significantlyaffected the overall score which indicated that these two variablessignificantly affected the educationalenvironment. Further studies are recommended with large sample size andseveral regions.