Postgraduate medical trainees at a Ugandan university perceive their clinical learning environment positively but differentially despite challenging circumstances: a cross-sectional study | BMC Medical Education

The PHEEM survey

Out of 113 residents invited to participate in the survey, 90 (79.6%) responded and completed the questionnaire. Of these, 62 (68.9%) were male, 51 (56.7%) were year 3 trainees, and the majority of participants were aged between 30 and 34 years. Participants represented 12 clinical departments that train specialists for a three-year period; at the time of the study only second- and third-year postgraduate trainees met the criteria for inclusion into the study, as the first-year trainees had just commenced their first semester of training. Socio-demographic data for the participants are shown in Table 1.

Cronbach’s alpha coefficient for the overall PHEEM tool was 0.94, for the role autonomy subscale was 0.83, for the teaching subscale was 0.93, and for the social support subscale, it was 0.74. A chi-square test of independence showed that there was no significant association between gender and age category, X² (1, N = 90) = 6.4, p = .169; or gender and year of postgraduate training, X² (1, N = 90) = 0.1586, p = .69.

The mean total PHEEM score was 98.22 ± 38.09, with the three sub-scales scoring 34.25 ± 13.69 for Role Autonomy, 39.7 ± 13.81 for Teaching, and 24.27 ± 10.59 for Social Support (Table 2). The items that scored the lowest were question 2: “I have a contract of employment that provides information about hours of work” (Mean, 0.85 ± 0.94), question 30: “There are adequate catering facilities when I am on call” (Mean, 1.11 ± 0.99), and question 33: “This hospital has good quality accommodation for residents, especially when on call” (Mean, 0.66 ± 0.91).

There were significant gender differences in the individual scores for six items in the perceptions of teaching and one item in the perception of social support domain (Table 3). Across all six items in the teaching domain, males consistently ranked their perceptions of teaching higher than the females. For the single gender difference in the domain for perception of social support, males rated higher scores for good collaboration with other residents (Table 3).

In all the statistically significant comparisons shown, males consistently scored higher than females on the items shown.

When postgraduate trainees’ responses were compared by the sources of funding for their training, significant differences existed for one item in the domain for perception of teaching (item 27). Significant differences also existed by funding source for three items in the perception of social support (Table 4).

Qualitative findings

Analyses of the transcribed data showed 5 major themes with a number of sub-themes as indicated in Table 5.

Trainee support

Many trainees aspire to certain ideals during and after training. Seeing their transition from novices to proficient practitioners of their specialties is exciting and motivates individuals along their career paths despite the uncertain journey from novice to proficient practitioner, perhaps even mastery. Participants acknowledged the importance of support, both emotional and intellectual, during training. One participant observed:

“…we hold different activities within the department including case conferences and journal clubs and therefore these are done in presence of all seniors most of the time, and so they keep guiding us and teaching us…yeah, so that we improve at the next presentation.”

Most of the participants valued the support given by peers and supervisors during training. One trainee in Pathology pointed out:

“…[availability of supervisors] gives us a chance to always interact with them on a daily basis right from the time of lectures, to reading slides, the time of signing out cases.”

One of the ways many trainees felt supported was through orientation when they started their training and during different periods of their training. Trainees valued the orientation that was provided on the educational goals, expectations, structure of the clinical services at their training stations, and opportunities available after training. One trainee observed,

“…we get to learn our limits… we learn our limitations…as residents, we get to know at what point do we get to call the specialists, there are actually protocols where some of them are clearly put. A specialist needs to be called, informed about this case within this and this time.”

Supervision environment

For many residents, being able to work independently but with supervision from faculty provided an opportunity to satisfactorily engage with their supervisors during their training. Many residents appreciated the importance of the supervision of their teaching activities when they prepare to make presentations:

“Seniors are there to see how you have prepared your slides, how you present your material and how you, ah, emotionally handle yourself.”

Moreover, many residents highlighted the significance of their seniors and academic supervisors as role models in their academic preparation to practice.

Engagement with overall learning environment

Many residents perceived that overall they were satisfactorily engaged with the learning environment and recognized that the environment provided insights into mistakes made during training. One trainee observed,

“When I reflect back I see things that I, I could actually…if faced now I actually do differently, I face with confidence and I can tell what…I feel more in charge [pauses] personally as a postgraduate student.”

Aspects of the learning environment that were perceived as enhancing training and practice included the availability of patients as a resource, collegial faculty, learning that was trainee-centered, and orientation on opportunities after they completed their training.

Many trainees perceived their learning environment as building their competencies:

“…largely the hands-on experience we have in the department, it’s quite practical in the different aspects of the study, so that’s a good thing. The second is that most, majority of the aspects in studying, uh, are sort of student-led, and I think that is a good thing as opposed to just being fed information.”

Trainees appreciated the collegial environment present in their clinical training. One participant commented,

“…you will find a senior on the ward, and they are also very friendly to us, they treat us like we are colleagues, and also they mentor us, yeah. They have formed mentorship groups and our mentors look out for us so much.”

Preparation for future practice

Participants perceived the learning environment as one that provides a suitable preparation for their future practice despite some of the challenges such as heavy workloads. One participant observed,

“I have really got a chance to see many cases which I am really happy about, so despite the heavy workloads, I think it uh, that prepares me for my next uh…phase.”

Participants felt strongly that in spite of the limitations of training equipment and information resources, the availability of a rich patient resource prepared them for their future practice in their specialty. A participant from Internal Medicine commented:

“I think anyone who has gone through this system will probably do well out there, because uh, you know, eh, patients is also a resource (sic), and the condition they present to us is also a resource…”.

Another participant from Surgery department:

“…most of the conditions that we would wish to be exposed to they are readily available and we never lack the number of patients that we are interested in.”

Challenges that impede trainee engagement

Intertwined with participants’ aspirations and ideals were perceptions of challenges relating to engagement during training and preparation for future practice, which was a major theme.

The first subtheme included challenges related to training support structures. Some residents expressed dissatisfaction with interpersonal relationships between themselves and their academic faculty: One trainee commented,

“…some lecturers lack proper communication skills, eh, so they push you into depression because you are stressed all the time, you can’t breathe, you are scared to enter the hospital because each day you are looking up to another day where you are going to be rebuked, and in a rather, um, immature way…yeah.”

Another trainee observed, “You are either stressed by the lecturer or by the nurses, because as a resident you know this is an emergency or not. You will see a patient and think, I will review them later. But then the nurse wants you to see them at that very minute and if you don’t see them they go and report to your lecturer who is going to grill you, yet that very lecturer wants work the next morning. So…it’s quite taxing and very depressing.”

A few trainees perceived the inadequacy of orientation at the start and during their training as a challenge. One trainee observed,

“…unfortunately orientation is just a two-hours’ talk and that is all. Afterwards it is baptism by fire and even for the students who don’t know how things go here it is usually very difficult.

The second subtheme involved trainees’ perceptions that the limitations in physical infrastructure were a challenge in their training. These limitations included limited physical space, limitations in the availability of equipment during training, and inadequate exposure to resources routinely used in their specialties.

One participant observed,

“I feel like if it was…all these resources were available to us more often we would get a richer experience and having, you know, that specialist training on them.”

Another participant observed, “…as a specialist in training, there are some, common, uh, investigations, that we should be able to familiarize ourselves with, I am thinking echocardiography, ECG, and these should be readily available to us, but unfortunately, they will guide me if I am wrong, we don’t get that.

A third subtheme involved many trainees recognizing challenges with integrating work responsibilities and learning, and considered the balance unsatisfactory. One trainee remarked,

“…you find we have a lot of clinical work, most colleagues who are on certain stations can be in clinical work all day, until late evening, 6.30[p.m.] when you are…if you are lucky to break off at that time, if you are not on call. But if you are on call, you will continue your duty until tomorrow, and tomorrow will still be the same similar day. You will continue your duty. So, if this person has a lecture, he’ll miss.

The last subtheme involved challenges with limitations in training frameworks and policies. Although many trainees perceived that they were familiar with their limits during training, some decried the deficiency in communication and guidance during their training. One trainee commented,

“…I don’t think our roles and even the resources were made clear…uh…as for me I learnt on job, many, many things, and generally in terms of general resource, ah, provision and preparation… we are not generally guided even before the course on where to go and find information… personally struggled to get access to information…”.

Some of the trainees perceived the lack of clear policies regarding their training as a challenge that impeded their training. A trainee remarked,

“…it seems like the ones who are supposed to inform of our limitations also don’t know how far the residents are supposed to go, eh. Ah, for example, like you can do something…um, one senior thinks it is okay, and then the other senior thinks it is not okay. So you get confused, eh, you are torn in between…am I okay, am I supposed to do this, eh?”