Trainees ’ perception of the clinical learning environment in the postgraduate training programme in paediatrics

Working and learning in the clinical environment represents a challenging phase for doctors in training. According to Daugherty et al., they '...must learn to balance such diverse demands as responsibility for patient care, economic hardships, on-call schedules, patient death, the need for constant learning, the task of teaching, the requirements of attending physicians and senior residents, along with the necessities of family and personal life' .


Introduction
Working and learning in the clinical environment represents a challenging phase for doctors in training.According to Daugherty et al., they '…must learn to balance such diverse demands as responsibility for patient care, economic hardships, on-call schedules, patient death, the need for constant learning, the task of teaching, the requirements of attending physicians and senior residents, along with the necessities of family and personal life' 1 .
One important component of the educational experience is the clinical learning environment.This environment encompasses many important aspects, such as the quality of supervision (autonomy) 2,3 , the quality of teachers 4,5 , and facilities and atmosphere (social support) 6,7 .The Standing Committee on Postgraduate Medical Education (SCOPME) stated that '…a working environment that is conducive to learning is critically important to successful training' 8,9 .
The postgraduate training programme in paediatrics comprises 3 stages of training.The first year of training is in a general hospital (Kalutara, Ratnapura, Kurunegala, Anuradhapura, Badulla or Matara).The second year of training is in a teaching hospital (Colombo South Teaching Hospital, Colombo North Teaching Hospital, Sri Jayawardenapura General Hospital, Teaching Hospital Karapitiya, Teaching Hospital Kandy or Teaching Hospital Peradeniya).The third and final year of training is at Lady Ridgeway Hospital for Children, Colombo.• To compare the clinical environment between the 3 different stages of training.

Method
It was an observational descriptive study.respectively.There was a significant difference between the 3 stages p=0.028(p<0.05)(Figure 1).The statements representing autonomy are as follows: 1.I am provided information about the time allocated for the various components in the training programme.

I had an informative introduction programme.
3. There is an informative junior doctor's handbook.4. I have the appropriate level of responsibility in this post.5.I have to perform inappropriate tasks.6.I am called inappropriately.All stages of trainees identified strengths and weaknesses in the 3 categories of the clinical learning environment.
Strengths identified in autonomy were: • I have the opportunity to provide continuity of care.• I feel part of a team working here.
• I have opportunities to acquire the appropriate practical procedures for my grade.
• I do not have to perform inappropriate tasks.
Weaknesses identified in autonomy were: • No formal informative introduction programme.

• No clear management guidelines.
Strengths identified in social support were: • No sex discrimination in this post.Weaknesses identified in social support were: • Accommodation provided is of poor quality.• Catering facilities are very poor.
• Counselling opportunities for those who fail to complete their training is unsatisfactory.
Strengths identified in teaching were: • My clinical teachers set clear expectations.
• Clinical teachers are enthusiastic.
• My clinical teachers have good teaching skills.

• My clinical teachers are accessible.
Weaknesses identified in teaching were: • No protected time.
• No access to relevant educational programmes.
Weaknesses identified only by the stage 3 trainees were: • Heavy workload • Lack of an atmosphere of mutual respect • Lack of access to suitable career advice • "Blame culture" • Lack of job satisfaction • Inability to participate actively in educational events

Discussion
The education of trainees relies on an integration of didactic activity in a structured curriculum with diagnosis and management of patients under appropriate levels of supervision and scholarly activity aimed at developing and maintaining lifelong learning skills.The quality of this experience is directly related to the quality of patient care, which is always the highest priority.Educational quality and patient care quality are interdependent and must be pursued in such a manner that they enhance one another.A proper balance must be so that a programme of postgraduate medical education does not rely on residents to meet service needs at the expense of educational objectives 11 .
The World Federation for Medical Education has laid down standards for postgraduate education some of which are mentioned below.
• Professionalism and autonomy-the training process must, based on approved basic medical education, further strengthen professionalism of the doctor and the training should foster professional autonomy to enable the doctor to act in the best interests of the patient and the public.
• The relationship between training and servicethe apprenticeship nature of professional development must be described and respected and the integration between training and service (on-the-job training) must be assured and the capacity of the health care system should be effectively utilised for service based training purposes.The training provided should be complementary and not subordinate to service demands.
• Feedback to trainees -constructive feedback on the performance of the trainee must be given on an ongoing basis and acceptable standards of performance should be explicitly specified and conveyed to both trainees and supervisors.
• Support and counselling of trainees -the competent authorities must, in collaboration with the profession, ensure that a system for support, counselling and career guidance of trainees is available..This is the standard set by the World Federation for Medical Education.So, where do we stand?This study shows that there are several areas in the pre-MD training programme that need improvement (identified weaknesses).
A disparity was noted between the different stages of the paediatric training programme with regard to their clinical learning environment.
The postgraduate pre-MD training programme in paediatrics has evolved over time and was divided into 3 stages only in 2002.At this time there was controversy whether spending one year in the peripheral hospital would actually be beneficial to the trainees due to scarcity of clinical material.However the stage 1 trainees have scored the highest with regard to the overall satisfaction of the training programme as well as in all 3 sub categories.
The stage 3 trainees are based at the tertiary care hospital for children, Lady Ridgeway Hospital and are thought to have the ideal clinical learning environment.However, they showed the least amount of satisfaction with regard to the overall training programme as well as its 3 subcategories.
It should be remembered, however, that the stage 3 trainees have the most amount of stress, as the MD (Paediatrics) part 2 examination is near at hand and they have to cope up with a much heavier work load, giving them little time to study.This may partly account for lowest level of satisfaction seen among this group.

Conclusion
Stage 3 trainees have shown the least amount of satisfaction in contrast to the stage 1 trainees who have shown the highest amount of satisfaction, with regard to the clinical learning environment as a whole and in all 3 sub categories.

Recommendations
• A workshop should be held for the trainers and trainees to rectify the problems identified in stage 3.
• The weaknesses identified in the different stages should be conveyed to the trainers via the Board of Study in Paediatrics.
• Different tutors should be assigned to trainees who fail to complete their training programme.
• Follow up studies should be performed annually.
An introduction programme has been started for the new batch of trainees enrolled.The availability of the National Guidelines (which occurred after this study was done) has somewhat solved the problem of not having clinical guidelines for the post.
The work environment will thereby differ according to the stage of training.It is of interest to assess and compare the work environment in each of these stages and to determine whether it _________________________________________ 1 Paediatric Registrar, Colombo South Teaching Hospital, 2 Senior Lecturer & Head, Department of Paediatrics, University of Sri Jayawardenapura.(Received on 01 January 2008.Accepted on 20 January 2008) facilitates a successful training programme in paediatrics.No study has so far been published with regard to the clinical learning environment in a postgraduate training programme in Sri Lanka.This study was conducted to assess the clinical learning environment in each stage of training in the postgraduate paediatric training programme.Objectives • To assess the overall clinical learning environment in the postgraduate pre-MD training programme in paediatrics.

Figure 1
Figure 1 Mean total overall scores obtained from trainees of the 3 stages P values were calculated to determine whether stage 3 was significantly lower than the other 2 stages.Stages 1 and 3 p=0.014;p<0.05 Stages 2 and 3 p=0.034;p<0.05 Stages 1 and 2 p=0.733; p>0.05 7. There are clear clinical management guidelines in this post.8. My on call rotation conforms to the recommended 1 in 3. 9.I have the opportunity to provide continuity of care.10.I feel part of a team working here.11.I have opportunities to acquire the appropriate practical procedures for my grade.12. My workload in this job is fine.