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The Clinical Learning Environment

• Total D-RECT score provides a global, composite measure of trainee views of the clinical learning environment. D-RECT scores range from 50 to 250. a higher total D-RECT score indicates a more positive view of the clinical learning environment.
• The national mean total D-RECT score across all trainees in Ireland in 2014 was 170.8.
• There was very wide variation in trainee views of the clinical learning environment: 25% reported scores lower than 151.3 and 25% reported scores higher than 192.7.
• The mean total D-RECT score from experts who rated their expectations for the clinical learning environment (mean total D-RECT score 203.9) was almost 20% higher than trainee-rated experience.
• Trainee experience in 2014 was similar to experience reported in smaller study of irish trainees in 2012 (mean total D-RECT score 173); it was less positive than the experience reported by dutch trainees in 2010 (mean total D-RECT score 188).

Different attributes of the clinical learning environment

• The views of trainees point to strengths and weaknesses in different attributes of the clinical learning environment. in general, training rating of different attributes were lower than expert expectations.
• Overall, at national level, strengths of the clinical learning environment included “consultants’ role”, “teamwork” and “Peer collaboration”; weaknesses included “Feedback”, “Professional relations between consultants” and “role of the educational supervisor”.

Variations in views of the clinical learning environment

• Younger trainees generally reported poorer views of the clinical learning environment.
• Trainees who were graduate-entry medical students also reported poorer views of the clinical learning environment than trainees who were direct-entry medical students; this difference was not related to age differences among younger trainees, but among older trainees there was no difference in views of the clinical learning environment by route of entry to medical school.
• Compared with internationally qualified trainees, irish qualified trainees reported poorer views of the clinical learning environment.
• Interns reported poorer views of the clinical learning environment than trainees at all other stages of training. the poorer views of interns does not relate to their younger age, since interns of different ages had similar views.
• There was very wide variation in views of the clinical learning environment across specific sites (25% of sites had total D-RECT scores less than 167.0 and 25% had scores greater than 194.3).
• Size of clinical site did not affect trainee views of the clinical learning environment; however, type of site was relevant: in general, trainees had more positive views of the clinical learning environment at mental health services (mean total D-RECT score 190.9) and GP practices (mean total D-RECT score 183.4) than at hospitals (mean total D-RECT score 166.2 for smaller hospitals and 167.8 for larger hospitals).

Induction to the clinical environment

• While most trainees reported a positive overall experience of induction and orientation to the clinical environment as a place to work and learn, many trainees identified deficiencies in core areas: discussing educational objectives with their educational supervisor (absent for 43.5% of trainees), receiving basic information about the workplace (absent for 35.3% of trainees) and explanation of their role and responsibilities (absent for 28.9% of trainees).
• An experience of good induction to the clinical site, for example through discussing educational objective with an educational supervisor, was associated with trainees having a better view of the overall clinical learning environment.
• The views of trainees in Ireland on induction and orientation were poorer than the views of their UK counterparts; for example, 9-in-10 trainees in the UK reported having discussed educational objectives with an educational supervisor, compared with 5-in-10 trainees in Ireland.
• In general, trainees at intern and basic specialist training stages reported poorer experiences of induction and orientation to the clinical site as a place to work and learn; for example, 7-in-10 higher specialist trainees and registrar trainees rated induction as at least good, compared with 5-in-10 intern and basic specialist trainees.
• Trainee-reported experience of induction and orientation was poorer at hospitals than at GP practices and at mental health services: for example, 7-in-10 trainees at mental health sites rated induction as at least good, compared with 5-in-10 trainees at smaller hospitals.

Preparedness for transitions

• Male and female trainees had similar views of the overall clinical learning environment, but trainee views varied by other trainee-related characteristics.
• Almost 9-in-10 trainees completing specialty training felt they had been well prepared for their next role.
• In contrast, approximately 3-in-10 interns reported that their previous medical education and training did not prepare them well for intern training. The prevalence of this issue among trainees in Ireland is 2-3 times greater than among their UK counterparts.
• For 5-in-10 interns who reported that preparedness was an issue, lack of preparedness was a ‘medium-sized’ or ‘serious’ problem. Again, for those who felt under-prepared, compared with their UK counterparts, trainees in Ireland were 2 times more likely to report that the problem was significant.
• While feeling unprepared was less commonly reported with respect to clinical knowledge and interpersonal skills, the problem more commonly arose with regard to administrative duties and the physical/emotional demands of clinical work as an intern.
• It is important to note that the prevalence of feeling underprepared was not associated with traineerelated characteristics. Critically, the problem was no more or less common for interns depending on their medical school of graduation or the intern training network overseeing their intern learning experience.
• Interns who rated the quality of induction to the clinical environment positively were more likely to also report that they felt well prepared for intern training.
• Interns who felt less well prepared for intern training reported a poorer experience of the clinical learning environment; for those who reported the problem to be more serious, their experience of the clinical learning environment was worse.

Bullying and undermining behaviour

• Based on trainee-reported experience, bullying and undermining behaviours were endemic in the clinical learning environment. In total, approximately 3-in-10 trainees reported personal experience of bullying and undermining behaviour, and this experience was over 2 times more prevalent than for their UK counterparts. Where bullying and undermining behaviour was experienced, the frequency was greater among trainees in Ireland compared with their UK counterparts.
• The prevalence of trainee-reported personal experience of bullying and undermining behaviours was greater among younger trainees and among those at the intern stage of training.
• Type of clinical site was relevant: the prevalence of trainee-reported personal experience of bullying and undermining behaviours was greater among trainees at hospitals than among trainees at GP practices.
• Trainee-reported experience of bullying and undermining behaviours was associated with a poorer trainee view of the clinical learning environment.

Safety and quality of care at clinical sites

• Over 8-in-10 trainees felt physically safe at the clinical site where they trained; 1-in-20 did not.
• Trainees with poorer views of the quality of induction at the clinical site were more likely to report that they did not feel safe.
• Trainees who reported that they did not feel safe at the clinical site also reported poorer views of the clinical learning environment.
• Over 8-in-10 trainees rated the quality of care at the clinical site where they trained as good or very good.
• Compared with other trainees, interns had a poorer view of the quality of care; trainees at smaller hospitals also had poorer views on the quality of care.
• Trainees who reported a positive experience of induction at the clinical site were also more likely to rate the quality of care as good or very good; interns who felt prepared for intern training were also more likely to positively rate the quality of clinical care.
• Trainees who rated the quality of care at the clinical site as good or very good reported most positive views of the clinical learning environment.