Measuring Clinical Learning Environment across three residency programs using a Postgraduate Hospital Educational Environment Measure (PHEEM) scale at a tertiary care hospital in the United Arab Emirates

Measuring Clinical Learning Environment across three residency programs using a Postgraduate Hospital Educational Environment Measure (PHEEM) scale at a tertiary care hospital in the United Arab Emirates | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Measuring Clinical Learning Environment across three residency programs using a Postgraduate Hospital Educational Environment Measure (PHEEM) scale at a tertiary care hospital in the United Arab Emirates Nouf AlBisher, Fayeza AlAmeri, Dolhyt Detera, Humariya Heena This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4518993/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The Clinical Learning Environment Review (CLER) is used to evaluate the quality of education and the learning environment for hospital trainees for enhanced patient safety and healthcare quality. The focus areas include practical application of theoretical knowledge, acquisition of clinical skills, and development of problem-solving abilities. Continuous assessment, regular evaluation, and targeted interventions are needed to ensure an environment that supports effective learning and professional development. Methods Participants from three residency programs at a Military Hospital in the United Arab Emirates (UAE), were evaluated as per three PHEEM domains with areas of improvement. After study approval, the PHEEM questionnaire was administered online platform after informed consent, with slight modifications for cultural inclusivity and relevance. Results Data analysis was done using SPSS Statistics Version 22.0. with the Mann-Whitney U test and the Kruskal-Wallis H test, and a p < 0.05. Majority of the trainees were males and Emergency Medicine residents. Perceptions of role autonomy and perceptions of teaching had a mean score of 38.7 (out of 52) and 45.9 (out of 60), respectively, indicating a generally positive outlook, while perception of social support had a mean score of 33.0 (out of 44). Likewise, the total mean study score was 117.7 out of 156. The mean scores for all items ranged from 2.51±1.03 to 3.31±0.58. Areas of improvement were identified for collaboration with other doctors in the same year, while trainees were mostly satisfied with good quality accommodation for junior doctors on call. The results revealed no significant variations in the scores across different strata, although a slightly higher perception of social support was noted among female students. Overall, this study provides insights into the perceptions of the training environment, shedding light on potential areas for improvement in the professional and educational environment at a tertiary care hospital in the Middle East. Clinical Trial Number Not applicable. Figures Figure 1 Introduction The Accreditation Council for Graduate Medical Education International (ACGMEI) has mandated the Clinical Learning Environment Review (CLER) to assess the quality of education and learning environment provided to trainees to enhance patient safety and healthcare quality in accredited institutions through the Next Accreditation System. In addition, its focal areas include applying theoretical knowledge to practice, acquiring clinical skills, and developing problem-solving and clinical reasoning skills ( 1 ). Published reports suggest that CLER contributes to enhanced learning, performance, satisfaction, and success, but can also lead to trainee burnout if perceived negatively. ( 2 ). The importance of nurturing a favorable CLE cannot be overemphasized, as it contributes to efficient learning, professional development, the quality of patient care, and the institution's overall performance. Various studies have shown that a favorable CLE positively links with enhanced on-the-job learning, improved test scores, and heightened career satisfaction, while an adverse outcome has been linked to trainee fatigue and decreased patient care quality. Nevertheless, the complexity of the CLE needs active maintenance and continuous assessment, regular evaluation, and focused interventions to guarantee an atmosphere that supports efficient learning and professional development ( 3 ). Prioritizing the continuous appraisal and improvement of the CLE remains vital for preserving a supportive and enriching educational environment that encourages the advancement and well-being of both learners and the broader medical establishment ( 4 ). In recent times CLE in teaching hospitals have received considerable attention with greater emphasis on ensuring duty hours’ adherence, on call room availability and fatigue management ( 5 ). Directorate of Health is the apex governing authority for medical education in the Emirate of Abu Dhabi. There are at least 8 medical schools in the whole of UAE and despite a large number of hospitals offering different residency programs in the Emirate of Abu Dhabi, only a handful of studies have surveyed the Clinical Learning Environment. To date PHEEM as an instrument to assess CLER has been used by one study done in Dubai while another one in Abu Dhabi assessed the learning environment using CLER focal area questions only ( 5 , 6 ). Our study is one of the few to employ the PHEEM scale to measure the CLE in three residency programs in the United Arab Emirates (UAE) and to compare perceptions of the CLE by gender, level of training, and work experience. The study uses the three domains of PHEEM to shed light on the perceptions and highlight the strengths and opportunities for improving the residency programs. Material and Methods A cross-sectional study was conducted from December 2023 until March 2024 amongst the residents at Zayed Military Hospital in Abu Dhabi across three streams of specialization. Zayed Military Hospital is a 330 bedded hospital located in the heart of Abu Dhabi accredited for 3 specialization programs namely Internal Medicine, Emergency Medicine and Family Medicine. The objectives of CLER focus areas are identified each year by periodic meetings by the faculty with an assessment of areas of improvement as well. Clear cut benchmarks are set to provide residents with the best possible education and training. In this study, an internationally validated self-administered questionnaire (PHEEM) was used ( 7 ). The three major domains of PHEEM were assessed: Perception of autonomy, perception of teaching and perception of social support. The 40 item questionnaire was modified in few places as follows: Under the question “There is racism in this post” the following sub questions were added to clarify the meaning in the context of the cultural inclusivity in UAE. “There is equal opportunity regarding the yearly bonus” “Equal opportunities are provided for electing the president of resident association” “Equal opportunities are provided regarding other benefits.” Furthermore, considering the distinct social and cultural norms or expectations of behaviour in UAE, the following sub questions were added to the question “There is sex discrimination in this post” and “Consideration is given to females for them to avoid areas requiring physical strength” “Females are treated differently due to cultural norms here” Prior to the distribution of the questionnaire, consent forms were sent to the participants, detailing the procedures of the study. Residents who consented to participate in the study were sent the questionnaire via Microsoft Forms, a web-based application that allows users to create and distribute surveys. This method was chosen to facilitate completion of the questionnaire and to minimize the time required for data collection. In order to protect the privacy of the participants, no identifying information, such as registration numbers or names, was collected. Two reminders were sent to participants who had not yet completed the survey after the initial distribution. The results of the survey were recorded in an Excel spreadsheet. Participants were instructed to read each statement carefully and to respond using a five-point Likert scale ranging from strongly agree to strongly disagree. It was emphasized that each participant should apply the items to his or her own current learning situation and respond to all 40 questions. The PHEEM scale was scored as follows: 4 points for strongly agree (SA), 3 points for agree(A), 2 points for uncertain(U), 1 point for disagree(D), and 0 points for strongly disagree(SD). However, four of the 40 items (numbers 7, 8, 11, and 13) were reverse-scored, meaning that 0 points were assigned for SA, 1 point for A, 2 points for U, 3 points for D, and 4 points for SD. The 40-item PHEEM has a maximum score of 160 indicating the ideal educational environment as perceived by resident. A score of 0 is the minimum and would be a very worrying result for any medical educator. The overall score of 81–120 was considered more positive than negative but room for improvement. The PHEEM can also be used to pinpoint more specific strengths and weaknesses within the educational climate. Items that have a mean score of 3.5 or over are real positive points. Any item with a mean of 2 or less should be examined more closely as they indicate problem areas. Items with a mean between 2 and 3 are aspects of the climate that could be enhanced. The study was approved by the Research and Ethical Committee of Zayed Military Hospital. A pilot study was conducted on ten residents from three specialties who answered the questionnaire without facing any difficulties. Data analysis All data was gathered in Microsoft Excel. Data was analysed in IBM SPSS Statistics Version 22.0 (IBM Corp, Armonk, NY, USA). The statistical significance for all calculations was set at p < 0.05. Frequencies and percentages for all items in the questionnaire and mean ± standard deviation for continuous variables were calculated. Scores from 0–4 were assigned from the 5-point Likert scale PHEEM questionnaire responses. Where 0='Strongly Disagree’ to 4= ‘Strongly Agree’, scores were reversed for negative questions (Q7, Q8, Q11, Q13). Normality tests for the 3 subscales and global scores were conducted, whereas in the absence of it, the Kruskal-Wallis and Mann-Whitney U tests were conducted to see the association between participants' demographics and the PHEEM scale scores. Results Demographic Data: The majority of respondents identified as male (66.7%, n = 34) followed by female (29.4%, n = 15), with a small portion preferring not to disclose their gender (2.0%, n = 1). (See Fig. 1 ). The most common age range among respondents was 26–35 years old (n = 40, 78.4%). The highest frequency of respondents belonged to the PGY2 and PGY3 (both 23.5%, n = 12). The most frequently reported speciality among respondents was Emergency Medicine (33.3%, n = 17). (See Table 1 ). Table 1 Demographics Age 18–25 5 9.8 26–35 40 78.4 36–45 6 11.8 Year PGY1 9 17.6 PGY2 12 23.5 PGY3 12 23.5 PGY4 6 11.8 Other 12 23.5 Speciality Emergency 17 33.3 Family Medicine 16 31.4 Internal Medicine 16 31.4 Other 2 3.9 PHEEM Scale Scores for all items in the PHEEM questionnaire were calculated where results interpreted a more positive learning environment than a negative one. (See Table 2 ). Among the key findings, perceptions of role autonomy stand out with a mean score of 38.7 out of a maximum of 52, indicating a generally positive outlook towards job autonomy. This suggests that individuals feel a sense of empowerment and control over their roles, fostering a conducive work environment. Similarly, perceptions of teaching score notably high at 45.9 out of 60, reflecting a positive trajectory in teaching experiences. However, there's room for enhancement in perceptions of social support, with a mean score of 33.0 out of 44, suggesting a need for strengthening interpersonal connections and support networks within the professional setting. Overall, while the total mean study score of 117.7 out of 156 indicates a predominantly positive atmosphere, it also underscores areas for improvement. Table 2 PHEEM Scale Scores The overall mean ± SD for all items in the PHEEM questionnaire are given in Table 3 . The mean for all items ranged from 2.51 ± 1.03 to 3.31 ± 0.58. The lowest rated score was item 16 – I have a good collaboration with other doctors in my same year (2.51 ± 1.03) and the highest rated score was for item 20 - This hospital has good quality accommodation for junior doctors, especially when on call (3.31 ± 0.58). PHEEM subscales Total mean study score Max score Interpretation based Perceptions of role autonomy 38.7 (5.5) 52 A more positive perception of one's job Perceptions of teaching 45.9 (6.8) 60 Moving in the right direction Perceptions of social support 33.0 (4.9) 44 More positive than negative Total PHEEM Score 117.7 (15.9) 156 Is more positive than negative but room for improvement Table 3 PHEEM All Items Item Mean SD Perceptions of role autonomy Q 1 I have a contract of employment that provides information about hours of work. 3.00 0.80 Q 4 I had an informative induction program 3.13 0.69 Q 5 I have the appropriate level of responsibility in this post 3.25 0.52 Q 8 I have to perform inappropriate tasks 3.02 0.93 Q 9 There is an informative junior doctors/curriculum handbook 2.74 0.92 Q 11 I am bleeped inappropriately 2.60 1.12 Q 14 There are clear clinical protocols in this post 2.96 0.86 Q 17 My hours conform to what is required in internship guidelines 2.76 0.79 Q 18 I have opportunity to provide continuity of care 3.16 0.70 Q 29 I feel part of a team working here 3.18 0.56 Q 30 I have opportunities to acquire the appropriate practical procedures for my grade 2.96 0.72 Q 34 The training in this post makes me feel ready to be a SpR/consultant 3.04 0.69 Q 40 My clinical teachers promote an atmosphere of mutual respect 3.18 0.48 Cumulative scores of the above items out of 52 (Mean) 38.70 Perceptions of teaching Q 2 My clinical teachers set clear expectations 3.08 0.59 Q 3 I have protected educational time in this post 3.02 0.68 Q 6 I have good clinical supervision at all times 3.12 0.71 Q 10 My clinical teachers have good communication skills 3.16 0.61 Q 12 I am able to participate actively in educational events 2.96 0.77 Q 15 My clinical teachers are enthusiastic 3.10 0.64 Q 21 There is access to an educational program relevant to my needs 2.98 0.68 Q 22 I get regular feedback from seniors 3.12 0.68 Q 23 My clinical teachers are well organized 3.08 0.66 Q 27 I have enough clinical learning opportunities for my needs 3.00 0.66 Q 28 My clinical teachers have good teaching skills 3.08 0.63 Q 31 My clinical teachers are accessible 3.06 0.73 Q 33 Senior staff utilize learning opportunities effectively 2.98 0.71 Q 37 My clinical teachers encourage me to be an independent learner 3.18 0.48 Q 39 The clinical teachers provide me with good feedback on my strengths and weaknesses 3.12 0.55 Cumulative scores of the above items out of 60 (Mean) 45.90 Perception about social support Q 40 There is racism in this post 3.23 0.97 Q 13 There is sex discrimination in this post 3.23 0.86 Q 16 I have good collaboration with other doctors in my same year 2.51 1.03 Q 19 I have suitability access to careers advice 3.00 0.49 Q 20 This hospital has good quality accommodation for junior doctors, especially when on call 3.31 0.58 Q 24 I feel physically safe within the hospital environment 2.96 0.75 Q 25 There is no-blame culture in this post 2.78 0.94 Q 26 There are adequate catering facilities when I am on call 2.98 0.68 Q 35 My clinical teac0068ers have good mentoring skills 2.92 0.84 Q 36 I get a lot of enjoyment out of my present job 3.22 0.97 Q 38 There are good counseling opportunities for junior doctors who fail to complete their training satisfactorily 2.94 0.68 Cumulative scores of the above items out of 44 (Mean) 33.03 The items with mean scores falling between 2.5 and 3 in the provided dataset signify responses indicating moderate agreement or neutrality regarding various aspects of the professional environment. Notably, these responses neither strongly affirm nor negate the statements presented. For instance, respondents express a middling level of collaboration with peers in the same year (Q16) and occasional instances of inappropriate bleeping (Q11). Additionally, perceptions regarding the availability of an informative junior doctors /curriculum handbook (Q9) and adherence to internship guidelines regarding working hours (Q17) also fall within this moderate range of agreement. Moreover, the presence of a no-blame culture within the professional setting (Q25) and the effectiveness of clinical teachers' mentoring skills (Q35) evoke moderate levels of respondent agreement. Furthermore, statements about the existence of clear clinical protocols (Q14), opportunities for active participation in educational events (Q12), and access to relevant educational programs (Q21) similarly garner moderate levels of agreement. Additionally, respondents’ express moderate levels of assurance regarding the physical safety within the hospital environment (Q24) and the utilization of learning opportunities by senior staff (Q33). Moreover, the availability of adequate catering facilities during on-call duties (Q26) also falls within this moderate range of agreement. These findings underscore the nuanced perceptions held by respondents, indicating neither overt positivity nor negativity but rather a balanced stance or potential uncertainty in their evaluations. There were two modified questions apart from the PHEEM scale that delved into understanding more about the participants’ opinions on racism and sex discrimination. Few participants (15.7%, n = 8) strongly disagreed that there are equal opportunities regarding yearly bonuses, opportunities to elect the president of the resident association, and opportunities to be the beneficiary of other benefits. Further, participants also agreed (9.8%, n = 5) that consideration is given to women to avoid physically strenuous areas and females are treated differently due to cultural norms here, while few others strongly disagreed (7.8%, n = 4) and disagreed (5.9%, n = 3) to the same. Mann-Whitney U test and Kruskal-Wallis H test were employed to analyze the difference in the PHEEM scores across gender and year of study. The analysis concluded no statistically significant differences in the scores of PHEEM subscales or global scores across the gender and year of study. Albeit, the mean score of perception of social support was higher among female students (34.1 ± 5.9) compared to males (32.7 ± 4.3), with p = 0.08. The total mean score was also observed to be higher in females (120.6 ± 19.0) than in males (117.2 ± 14.4), p = 0.422). (See Table 4 ) Table 4 Gender –Score The mean score for all PHEEM subscales and the global score was observed to be higher among PGY4 students compared to the other year groups, although it was not statistically significant. (See Table 5 ) PHEEM subscales Total mean study score Mann-Whitney U p Female Male Perceptions of role autonomy 39.7 (5.3) 38.6 (5.4) 236.5 0.684 Perceptions of teaching 46.7 (8.3) 45.8 (6.3) 237.5 0.703 Perceptions of social support 34.1 (5.9) 32.7 (4.3) 176 0.085 Total PHEEM Score 120.6 (19.0) 117.2 (14.4) 218 0.422 Table 5 Year – Score PHEEM subscales Total mean study score Kruskal-Wallis H p PGY1 PGY2 PGY3 PGY4 Other Perceptions of role autonomy 38.8 (5.9) 38.1 (6.3) 37.5 (5.9) 42.6 (5.1) 38.5 (4.1) 4.304 0.366 Perceptions of teaching 45.6 (7.5) 46.9 (5.2) 44.4 (8.3) 51.1 (6.3) 44.1 (5.9) 6.048 0.196 Perceptions of social support 32.8 (5.6) 32.0 (4.3) 31.5 (6.1) 36.0 (5.5) 34.0 (2.6) 5.295 0.258 Total PHEEM Score 117.4 (18.3) 117.1 (14.0) 113.5 (19.3) 129 (15.6) 116.8 (11.1) 4.442 0.349 Discussion The residency program in the UAE follows the ACGMIE guidelines along with other boards. At our hospital, which is an exclusive military hospital for the UAE, we have a relatively young residency program. ACGMIE periodically evaluates the facilities available for postgraduate training to ensure that training standards are maintained and that junior doctors are accredited for continued training. However, local ways of administering programs or perceptions of the faculty might contribute to differences in the results between the US and UAE. Also, programs in community-based hospitals may show different results than ours. In this study, we tried to understand the perceptions of trainees and other environmental components that impact their learning experience to identify areas of improvement. The residents are in a constant phase of struggle with the work at the hospital, which includes taking care of sick and dying patients, taking an emotional toll on them in addition to pursuing their academics and research. On top of it, they have family and social contacts to take care of, more so for females. Hence, the quality of a learning environment in a teaching hospital goes a long way in providing solace and comfort to the residents in terms of an explicit curriculum and goals. Globally, PHEEM has been rated as a tool with excellent reliability, with Cronbach's alpha ranging from 0.84 to 0.95, constructed and validated by Roff ( 8 ). PHEEM The response rate and reliability of PHEEM in our study were high, in agreement with other studies ( 9 ). Our perceptions were mostly positive, not negative, albeit with a few elements. Our primary cause for concern was the strong disagreement of the few participants regarding equality in yearly bonuses, resident elections, and other benefits. However, there was a general agreement regarding the consideration given to females owing to the cultural norms prevalent here. The residents are more considerate towards work and learning balance, as indicated by their responses to questions regarding role autonomy questions. The overall score is higher, similar to other studies in the developing world probably due to experienced teaching staff, and variation in resident workload ( 10 , 11 , 12 , 13 ). In contrast, studies from African continent report a very low score of 80 or lower due to an apparent lack of healthcare facilities, policies, curriculum for residents, and implementation in practice ( 14 , 15 ). Unusually, studies from the region ( 16 , 17 , 18 , 19 ) showed a very low overall score of below 80, indicating plenty of problems in the residency program. High PHEEM scores are associated with better knowledge and exam performance ( 20 ). The overall maximum scores indicated no major issues in the learning environment. The items with lower mean values in this study were collaboration with other doctors in the same year, inappropriate bleeping, hours conforming to internship guidelines, and the availability of a handbook for doctors. The participants in this study did not feel the same about significant issues affecting a good learning environment like long working hours, unavailability of clinical protocols, inefficient use of training time, lack of constructive feedback, and presence of a blame culture, as in other similar studies ( 21 ). The low item points identified in our study are not difficult to fix, such as providing handouts which are management issues. However, inappropriate bleeping can lead to a stressful work environment, which can affect a conducive learning environment and require appropriate behavioral measures. Some of the items on the PHEEM questionnaire in our study received average scores of more than 2, which are far better than other studies, where most items received response scores below 2 on average ( 22 , 23 ). Conversely, majority of responses exceeded the mean value of 3, which means that our residents were mainly satisfied with most areas of the learning environment in all specialties. These areas included the availability of adequate catering facilities, physical safety within the hospital environment, and utilization of learning opportunities by the senior staff. However, there is scope for improvement. Our study reported no difference in gender responses, but the mean score and the total score for social support in females were higher than in males, which is in contrast to another study in the region ( 24 ). Marco Grech et al. found a significant difference in perception between the genders and like our study females had a better perception score than males ( 25 ). This can be explained by the fact that culture can affect the perceptions between males and females. In other studies, residents found problems with access to their supervisors (Ong, Andrew Ming-Liang, et al.), which is in contradiction to our study. Residents are provided with appropriate supervision feedback and mentoring support. This is due to the introduction of constant faculty development programs, including those for improving academic teaching skills. Our study showed that for PHEEM scores by level of training, senior trainees had better perceptions of the CLE, which is in agreement with Khoja et al. as residents learn to adapt to the work stressors over time and are in a better position to evaluate their residency experience. However, other studies do not find changes in perception about the year of residency ( 26 , 27 , 28 ). Hence, a longitudinal study can provide a better outlook on this aspect. Our study had limitations, the major being a cross-sectional study on a very small sample of residents. However, it had several strengths as it was not limited to one specialty only. We had an excellent response rate as the questionnaire was distributed online with reminders. All our respondents were proficient in English, and the chance of misunderstanding the questions was consequently very low. Our study is one of the few in the United Arab Emirates that examined the education environment for residents. The positive learning outcome of our study provides impetus for more youth in this country to pursue their medical residency at our hospital. Our study could motivate curriculum planners to enhance the quality of residency educational programs and to conduct further research to evaluate the educational environment and the outcomes in terms of patient care, clinical knowledge, and surgical skills in hospitals across the Middle East. Also, our residents need more opportunities to join renowned international medicine societies and present their research findings at international conferences and meetings. We believe that having hands-on educational material available at the time of resident onboarding is essential in addition to freely available counseling services for better interpersonal relationships between residents. Declarations Ethics approval and consent to participate The ethical approval was obtained from the Ethics Committee at Zayed Military Hospital, Abu Dhabi, UAE. The written informed consent forms were obtained from all participants. This study considered the principles of confidentiality of the information and the right to withdraw from the research. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This study was not funded and supported by any funding body. Author Contribution Author HH: substantially contributed to the conception or design; drafted and reviewed the manuscriptAuthor NA: contributed to acquisition, analysis, drafted and reviewed the manuscriptAuthor FA: interpreted the data, critically revised the manuscript for important intellectual content; gave final approval Author DD: interpreted the data, prepared the figures and tables;critically revised manuscript Acknowledgement We would like to thank Dr. Mohamed Hassan Taha for his help in result interpretation and the program directors at Zayed Military Hospital for their support in conducting this research. Data availability The datasets used and analyzed during the current study are available from the 1 ST author upon reasonable request. References Wiese A. (2018). Exploring clinical learning environments for postgraduate medical education. Jennings ML, Slavin SJ. Resident wellness matters: optimizing resident education and wellness through the learning environment. 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Evaluation of the learning environment for residency training in St. Paul’s Hospital Millennium Medical College. Ethiop Med J. 2018;56(1):11–6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4518993","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":322147559,"identity":"0e29e1d0-fdd2-4f59-8634-8cad3564a610","order_by":0,"name":"Nouf AlBisher","email":"","orcid":"","institution":"Zayed Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Nouf","middleName":"","lastName":"AlBisher","suffix":""},{"id":322147560,"identity":"86f9c821-d885-48e6-9fef-8ce7faf3c855","order_by":1,"name":"Fayeza AlAmeri","email":"","orcid":"","institution":"Zayed Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fayeza","middleName":"","lastName":"AlAmeri","suffix":""},{"id":322147563,"identity":"86176029-9e39-4294-9c73-1a0427d4e9d8","order_by":2,"name":"Dolhyt Detera","email":"","orcid":"","institution":"Zayed Military Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dolhyt","middleName":"","lastName":"Detera","suffix":""},{"id":322147564,"identity":"8b04fd31-a1b1-4257-807c-0a5aba404123","order_by":3,"name":"Humariya Heena","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACgwNgEoglEkAsG4hwQgHxWtKgWgwIaWGAazkME8ej5UZ24ueKgsPyDBLJBx8X1JyPlm8/wLrhgQGDPD8OLfY3cjdLnjE4bNgg/yzZeMax27kbziSw3QA6zHBmAy5bcjdINhgcZmyQyDGT5mEDapFgAGth3HAAp5bNP4Fa7Bsk8r//5vl3Lnf+DIgW+/24tWwD2ZIItIWNmbftQG7DDYiWxA24vH/m7TbLBoP05DaJNGNp3r5koF8S24BaJJJn4LLleO7mmw1/rG37JZIffub5Zpc7v/3wsZs/Kmxs+3F4HwqaGdgQHEaQWgm86oGgjpCCUTAKRsEoGMkAAA5XYraYSSGMAAAAAElFTkSuQmCC","orcid":"","institution":"Zayed Military Hospital","correspondingAuthor":true,"prefix":"","firstName":"Humariya","middleName":"","lastName":"Heena","suffix":""}],"badges":[],"createdAt":"2024-06-03 03:26:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4518993/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4518993/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60171033,"identity":"3b800815-e46b-4d2d-a463-82c66b721a22","added_by":"auto","created_at":"2024-07-12 15:08:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18305,"visible":true,"origin":"","legend":"\u003cp\u003eGender\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4518993/v1/96badf4ad54419bc47dad981.png"},{"id":62403493,"identity":"eaf6178d-7391-47cf-9dc9-8e3311da613e","added_by":"auto","created_at":"2024-08-13 19:49:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":588574,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4518993/v1/d12493b7-7f51-4313-ba55-504f36007d37.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":" Measuring Clinical Learning Environment across three residency programs using a Postgraduate Hospital Educational Environment Measure (PHEEM) scale at a tertiary care hospital in the United Arab Emirates","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe Accreditation Council for Graduate Medical Education International (ACGMEI) has mandated the Clinical Learning Environment Review (CLER) to assess the quality of education and learning environment provided to trainees to enhance patient safety and healthcare quality in accredited institutions through the Next Accreditation System. In addition, its focal areas include applying theoretical knowledge to practice, acquiring clinical skills, and developing problem-solving and clinical reasoning skills (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Published reports suggest that CLER contributes to enhanced learning, performance, satisfaction, and success, but can also lead to trainee burnout if perceived negatively. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe importance of nurturing a favorable CLE cannot be overemphasized, as it contributes to efficient learning, professional development, the quality of patient care, and the institution's overall performance. Various studies have shown that a favorable CLE positively links with enhanced on-the-job learning, improved test scores, and heightened career satisfaction, while an adverse outcome has been linked to trainee fatigue and decreased patient care quality. Nevertheless, the complexity of the CLE needs active maintenance and continuous assessment, regular evaluation, and focused interventions to guarantee an atmosphere that supports efficient learning and professional development (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Prioritizing the continuous appraisal and improvement of the CLE remains vital for preserving a supportive and enriching educational environment that encourages the advancement and well-being of both learners and the broader medical establishment (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recent times CLE in teaching hospitals have received considerable attention with greater emphasis on ensuring duty hours\u0026rsquo; adherence, on call room availability and fatigue management (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Directorate of Health is the apex governing authority for medical education in the Emirate of Abu Dhabi. There are at least 8 medical schools in the whole of UAE and despite a large number of hospitals offering different residency programs in the Emirate of Abu Dhabi, only a handful of studies have surveyed the Clinical Learning Environment. To date PHEEM as an instrument to assess CLER has been used by one study done in Dubai while another one in Abu Dhabi assessed the learning environment using CLER focal area questions only (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study is one of the few to employ the PHEEM scale to measure the CLE in three residency programs in the United Arab Emirates (UAE) and to compare perceptions of the CLE by gender, level of training, and work experience. The study uses the three domains of PHEEM to shed light on the perceptions and highlight the strengths and opportunities for improving the residency programs.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cp\u003eA cross-sectional study was conducted from December 2023 until March 2024 amongst the residents at Zayed Military Hospital in Abu Dhabi across three streams of specialization. Zayed Military Hospital is a 330 bedded hospital located in the heart of Abu Dhabi accredited for 3 specialization programs namely Internal Medicine, Emergency Medicine and Family Medicine. The objectives of CLER focus areas are identified each year by periodic meetings by the faculty with an assessment of areas of improvement as well. Clear cut benchmarks are set to provide residents with the best possible education and training. In this study, an internationally validated self-administered questionnaire (PHEEM) was used (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The three major domains of PHEEM were assessed: Perception of autonomy, perception of teaching and perception of social support. The 40 item questionnaire was modified in few places as follows: Under the question \u0026ldquo;There is racism in this post\u0026rdquo; the following sub questions were added to clarify the meaning in the context of the cultural inclusivity in UAE. \u0026ldquo;There is equal opportunity regarding the yearly bonus\u0026rdquo; \u0026ldquo;Equal opportunities are provided for electing the president of resident association\u0026rdquo; \u0026ldquo;Equal opportunities are provided regarding other benefits.\u0026rdquo;\u003c/p\u003e \u003cp\u003eFurthermore, considering the distinct social and cultural norms or expectations of behaviour in UAE, the following sub questions were added to the question \u0026ldquo;There is sex discrimination in this post\u0026rdquo; and \u0026ldquo;Consideration is given to females for them to avoid areas requiring physical strength\u0026rdquo; \u0026ldquo;Females are treated differently due to cultural norms here\u0026rdquo;\u003c/p\u003e \u003cp\u003e Prior to the distribution of the questionnaire, consent forms were sent to the participants, detailing the procedures of the study. Residents who consented to participate in the study were sent the questionnaire via Microsoft Forms, a web-based application that allows users to create and distribute surveys. This method was chosen to facilitate completion of the questionnaire and to minimize the time required for data collection. In order to protect the privacy of the participants, no identifying information, such as registration numbers or names, was collected. Two reminders were sent to participants who had not yet completed the survey after the initial distribution. The results of the survey were recorded in an Excel spreadsheet.\u003c/p\u003e \u003cp\u003e Participants were instructed to read each statement carefully and to respond using a five-point Likert scale ranging from strongly agree to strongly disagree. It was emphasized that each participant should apply the items to his or her own current learning situation and respond to all 40 questions. The PHEEM scale was scored as follows: 4 points for strongly agree (SA), 3 points for agree(A), 2 points for uncertain(U), 1 point for disagree(D), and 0 points for strongly disagree(SD). However, four of the 40 items (numbers 7, 8, 11, and 13) were reverse-scored, meaning that 0 points were assigned for SA, 1 point for A, 2 points for U, 3 points for D, and 4 points for SD.\u003c/p\u003e \u003cp\u003eThe 40-item PHEEM has a maximum score of 160 indicating the ideal educational environment as perceived by resident. A score of 0 is the minimum and would be a very worrying result for any medical educator. The overall score of 81\u0026ndash;120 was considered more positive than negative but room for improvement. The PHEEM can also be used to pinpoint more specific strengths and weaknesses within the educational climate. Items that have a mean score of 3.5 or over are real positive points. Any item with a mean of 2 or less should be examined more closely as they indicate problem areas. Items with a mean between 2 and 3 are aspects of the climate that could be enhanced.\u003c/p\u003e \u003cp\u003e The study was approved by the Research and Ethical Committee of Zayed Military Hospital. A pilot study was conducted on ten residents from three specialties who answered the questionnaire without facing any difficulties.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll data was gathered in Microsoft Excel. Data was analysed in IBM SPSS Statistics Version 22.0 (IBM Corp, Armonk, NY, USA). The statistical significance for all calculations was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Frequencies and percentages for all items in the questionnaire and mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for continuous variables were calculated. Scores from 0\u0026ndash;4 were assigned from the 5-point Likert scale PHEEM questionnaire responses. Where 0='Strongly Disagree\u0026rsquo; to 4= \u0026lsquo;Strongly Agree\u0026rsquo;, scores were reversed for negative questions (Q7, Q8, Q11, Q13). Normality tests for the 3 subscales and global scores were conducted, whereas in the absence of it, the Kruskal-Wallis and Mann-Whitney U tests were conducted to see the association between participants' demographics and the PHEEM scale scores.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic Data:\u003c/p\u003e \u003cp\u003eThe majority of respondents identified as male (66.7%, n\u0026thinsp;=\u0026thinsp;34) followed by female (29.4%, n\u0026thinsp;=\u0026thinsp;15), with a small portion preferring not to disclose their gender (2.0%, n\u0026thinsp;=\u0026thinsp;1). (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The most common age range among respondents was 26\u0026ndash;35 years old (n\u0026thinsp;=\u0026thinsp;40, 78.4%). The highest frequency of respondents belonged to the PGY2 and PGY3 (both 23.5%, n\u0026thinsp;=\u0026thinsp;12). The most frequently reported speciality among respondents was Emergency Medicine (33.3%, n\u0026thinsp;=\u0026thinsp;17). (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e78.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u0026ndash;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eYear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePGY1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePGY2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePGY3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePGY4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eSpeciality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFamily Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003ePHEEM Scale\u003c/h2\u003e \u003cp\u003eScores for all items in the PHEEM questionnaire were calculated where results interpreted a more positive learning environment than a negative one. (See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Among the key findings, perceptions of role autonomy stand out with a mean score of 38.7 out of a maximum of 52, indicating a generally positive outlook towards job autonomy. This suggests that individuals feel a sense of empowerment and control over their roles, fostering a conducive work environment. Similarly, perceptions of teaching score notably high at 45.9 out of 60, reflecting a positive trajectory in teaching experiences. However, there's room for enhancement in perceptions of social support, with a mean score of 33.0 out of 44, suggesting a need for strengthening interpersonal connections and support networks within the professional setting. Overall, while the total mean study score of 117.7 out of 156 indicates a predominantly positive atmosphere, it also underscores areas for improvement.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003ePHEEM Scale Scores\u003c/em\u003e The overall mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD for all items in the PHEEM questionnaire are given in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The mean for all items ranged from 2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03 to 3.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58. The lowest rated score was item 16 \u0026ndash; I have a good collaboration with other doctors in my same year (2.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.03) and the highest rated score was for item 20 - This hospital has good quality accommodation for junior doctors, especially when on call (3.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePHEEM subscales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal mean study score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMax score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eInterpretation based\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of role autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38.7 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eA more positive perception of one's job\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45.9 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMoving in the right direction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.0 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMore positive than negative\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PHEEM Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e117.7 (15.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIs more positive than negative but room for improvement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePHEEM All Items\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItem\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003ePerceptions of role autonomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 1 I have a contract of employment that provides information about hours of work.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 4 I had an informative induction program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 5 I have the appropriate level of responsibility in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 8 I have to perform inappropriate tasks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 9 There is an informative junior doctors/curriculum handbook\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 11 I am bleeped inappropriately\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 14 There are clear clinical protocols in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 17 My hours conform to what is required in internship guidelines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 18 I have opportunity to provide continuity of care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 29 I feel part of a team working here\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 30 I have opportunities to acquire the appropriate practical procedures for my grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 34 The training in this post makes me feel ready to be a SpR/consultant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 40 My clinical teachers promote an atmosphere of mutual respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCumulative scores of the above items out of 52 (Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e38.70\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerceptions of teaching\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 2 My clinical teachers set clear expectations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 3 I have protected educational time in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 6 I have good clinical supervision at all times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 10 My clinical teachers have good communication skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 12 I am able to participate actively in educational events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 15 My clinical teachers are enthusiastic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 21 There is access to an educational program relevant to my needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 22 I get regular feedback from seniors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 23 My clinical teachers are well organized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 27 I have enough clinical learning opportunities for my needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 28 My clinical teachers have good teaching skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 31 My clinical teachers are accessible\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 33 Senior staff utilize learning opportunities effectively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 37 My clinical teachers encourage me to be an independent learner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 39 The clinical teachers provide me with good feedback on my strengths and weaknesses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCumulative scores of the above items out of 60 (Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e45.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerception about social support\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 40 There is racism in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 13 There is sex discrimination in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 16 I have good collaboration with other doctors in my same year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 19 I have suitability access to careers advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 20 This hospital has good quality accommodation for junior doctors, especially when on call\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.58\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 24 I feel physically safe within the hospital environment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 25 There is no-blame culture in this post\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 26 There are adequate catering facilities when I am on call\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 35 My clinical teac0068ers have good mentoring skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 36 I get a lot of enjoyment out of my present job\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQ 38 There are good counseling opportunities for junior doctors who fail to complete their training satisfactorily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCumulative scores of the above items out of 44 (Mean)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e33.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe items with mean scores falling between 2.5 and 3 in the provided dataset signify responses indicating moderate agreement or neutrality regarding various aspects of the professional environment. Notably, these responses neither strongly affirm nor negate the statements presented. For instance, respondents express a middling level of collaboration with peers in the same year (Q16) and occasional instances of inappropriate bleeping (Q11). Additionally, perceptions regarding the availability of an informative junior doctors /curriculum handbook (Q9) and adherence to internship guidelines regarding working hours (Q17) also fall within this moderate range of agreement. Moreover, the presence of a no-blame culture within the professional setting (Q25) and the effectiveness of clinical teachers' mentoring skills (Q35) evoke moderate levels of respondent agreement. Furthermore, statements about the existence of clear clinical protocols (Q14), opportunities for active participation in educational events (Q12), and access to relevant educational programs (Q21) similarly garner moderate levels of agreement. Additionally, respondents\u0026rsquo; express moderate levels of assurance regarding the physical safety within the hospital environment (Q24) and the utilization of learning opportunities by senior staff (Q33). Moreover, the availability of adequate catering facilities during on-call duties (Q26) also falls within this moderate range of agreement. These findings underscore the nuanced perceptions held by respondents, indicating neither overt positivity nor negativity but rather a balanced stance or potential uncertainty in their evaluations.\u003c/p\u003e \u003cp\u003eThere were two modified questions apart from the PHEEM scale that delved into understanding more about the participants\u0026rsquo; opinions on racism and sex discrimination. Few participants (15.7%, n\u0026thinsp;=\u0026thinsp;8) strongly disagreed that there are equal opportunities regarding yearly bonuses, opportunities to elect the president of the resident association, and opportunities to be the beneficiary of other benefits. Further, participants also agreed (9.8%, n\u0026thinsp;=\u0026thinsp;5) that consideration is given to women to avoid physically strenuous areas and females are treated differently due to cultural norms here, while few others strongly disagreed (7.8%, n\u0026thinsp;=\u0026thinsp;4) and disagreed (5.9%, n\u0026thinsp;=\u0026thinsp;3) to the same.\u003c/p\u003e \u003cp\u003eMann-Whitney U test and Kruskal-Wallis H test were employed to analyze the difference in the PHEEM scores across gender and year of study. The analysis concluded no statistically significant differences in the scores of PHEEM subscales or global scores across the gender and year of study. Albeit, the mean score of perception of social support was higher among female students (34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9) compared to males (32.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3), with p\u0026thinsp;=\u0026thinsp;0.08. The total mean score was also observed to be higher in females (120.6\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0) than in males (117.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.4), p\u0026thinsp;=\u0026thinsp;0.422). (See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eGender \u0026ndash;Score\u003c/em\u003e The mean score for all PHEEM subscales and the global score was observed to be higher among PGY4 students compared to the other year groups, although it was not statistically significant. (See Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePHEEM subscales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal mean study score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMann-Whitney U\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of role autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39.7 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.6 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e236.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.684\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.7 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.8 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e237.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.1 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.7 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PHEEM Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120.6 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117.2 (14.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eYear \u0026ndash; Score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePHEEM subscales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eTotal mean study score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKruskal-Wallis H\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePGY1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePGY2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePGY3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePGY4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of role autonomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38.8 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.1 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.5 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.6 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.5 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.304\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of teaching\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.6 (7.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.9 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.4 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51.1 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e44.1 (5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.048\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.196\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceptions of social support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.8 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.0 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.5 (6.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.0 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.0 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal PHEEM Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e117.4 (18.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e117.1 (14.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e113.5 (19.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e129 (15.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e116.8 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.442\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e The residency program in the UAE follows the ACGMIE guidelines along with other boards. At our hospital, which is an exclusive military hospital for the UAE, we have a relatively young residency program. ACGMIE periodically evaluates the facilities available for postgraduate training to ensure that training standards are maintained and that junior doctors are accredited for continued training. However, local ways of administering programs or perceptions of the faculty might contribute to differences in the results between the US and UAE. Also, programs in community-based hospitals may show different results than ours.\u003c/p\u003e \u003cp\u003eIn this study, we tried to understand the perceptions of trainees and other environmental components that impact their learning experience to identify areas of improvement. The residents are in a constant phase of struggle with the work at the hospital, which includes taking care of sick and dying patients, taking an emotional toll on them in addition to pursuing their academics and research. On top of it, they have family and social contacts to take care of, more so for females. Hence, the quality of a learning environment in a teaching hospital goes a long way in providing solace and comfort to the residents in terms of an explicit curriculum and goals.\u003c/p\u003e \u003cp\u003eGlobally, PHEEM has been rated as a tool with excellent reliability, with Cronbach's alpha ranging from 0.84 to 0.95, constructed and validated by Roff (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). PHEEM The response rate and reliability of PHEEM in our study were high, in agreement with other studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur perceptions were mostly positive, not negative, albeit with a few elements. Our primary cause for concern was the strong disagreement of the few participants regarding equality in yearly bonuses, resident elections, and other benefits. However, there was a general agreement regarding the consideration given to females owing to the cultural norms prevalent here.\u003c/p\u003e \u003cp\u003eThe residents are more considerate towards work and learning balance, as indicated by their responses to questions regarding role autonomy questions. The overall score is higher, similar to other studies in the developing world probably due to experienced teaching staff, and variation in resident workload (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In contrast, studies from African continent report a very low score of 80 or lower due to an apparent lack of healthcare facilities, policies, curriculum for residents, and implementation in practice (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Unusually, studies from the region (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) showed a very low overall score of below 80, indicating plenty of problems in the residency program.\u003c/p\u003e \u003cp\u003eHigh PHEEM scores are associated with better knowledge and exam performance (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The overall maximum scores indicated no major issues in the learning environment. The items with lower mean values in this study were collaboration with other doctors in the same year, inappropriate bleeping, hours conforming to internship guidelines, and the availability of a handbook for doctors. The participants in this study did not feel the same about significant issues affecting a good learning environment like long working hours, unavailability of clinical protocols, inefficient use of training time, lack of constructive feedback, and presence of a blame culture, as in other similar studies (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe low item points identified in our study are not difficult to fix, such as providing handouts which are management issues. However, inappropriate bleeping can lead to a stressful work environment, which can affect a conducive learning environment and require appropriate behavioral measures.\u003c/p\u003e \u003cp\u003eSome of the items on the PHEEM questionnaire in our study received average scores of more than 2, which are far better than other studies, where most items received response scores below 2 on average (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Conversely, majority of responses exceeded the mean value of 3, which means that our residents were mainly satisfied with most areas of the learning environment in all specialties. These areas included the availability of adequate catering facilities, physical safety within the hospital environment, and utilization of learning opportunities by the senior staff. However, there is scope for improvement.\u003c/p\u003e \u003cp\u003eOur study reported no difference in gender responses, but the mean score and the total score for social support in females were higher than in males, which is in contrast to another study in the region (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Marco Grech et al. found a significant difference in perception between the genders and like our study females had a better perception score than males (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This can be explained by the fact that culture can affect the perceptions between males and females.\u003c/p\u003e \u003cp\u003eIn other studies, residents found problems with access to their supervisors (Ong, Andrew Ming-Liang, et al.), which is in contradiction to our study. Residents are provided with appropriate supervision feedback and mentoring support. This is due to the introduction of constant faculty development programs, including those for improving academic teaching skills.\u003c/p\u003e \u003cp\u003eOur study showed that for PHEEM scores by level of training, senior trainees had better perceptions of the CLE, which is in agreement with Khoja et al. as residents learn to adapt to the work stressors over time and are in a better position to evaluate their residency experience. However, other studies do not find changes in perception about the year of residency (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Hence, a longitudinal study can provide a better outlook on this aspect.\u003c/p\u003e \u003cp\u003eOur study had limitations, the major being a cross-sectional study on a very small sample of residents. However, it had several strengths as it was not limited to one specialty only. We had an excellent response rate as the questionnaire was distributed online with reminders. All our respondents were proficient in English, and the chance of misunderstanding the questions was consequently very low.\u003c/p\u003e \u003cp\u003eOur study is one of the few in the United Arab Emirates that examined the education environment for residents. The positive learning outcome of our study provides impetus for more youth in this country to pursue their medical residency at our hospital. Our study could motivate curriculum planners to enhance the quality of residency educational programs and to conduct further research to evaluate the educational environment and the outcomes in terms of patient care, clinical knowledge, and surgical skills in hospitals across the Middle East. Also, our residents need more opportunities to join renowned international medicine societies and present their research findings at international conferences and meetings. We believe that having hands-on educational material available at the time of resident onboarding is essential in addition to freely available counseling services for better interpersonal relationships between residents.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe ethical approval was obtained from the Ethics Committee at Zayed Military Hospital, Abu Dhabi, UAE. The written informed consent forms were obtained from all participants. This study considered the principles of confidentiality of the information and the right to withdraw from the research.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis study was not funded and supported by any funding body.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAuthor HH: substantially contributed to the conception or design; drafted and reviewed the manuscriptAuthor NA: contributed to acquisition, analysis, drafted and reviewed the manuscriptAuthor FA: interpreted the data, critically revised the manuscript for important intellectual content; gave final approval Author DD: interpreted the data, prepared the figures and tables;critically revised manuscript\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Dr. Mohamed Hassan Taha for his help in result interpretation and the program directors at Zayed Military Hospital for their support in conducting this research.\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the 1\u003csup\u003eST\u003c/sup\u003e author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWiese A. 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The American Journal of Surgery,217(2), 276\u0026ndash;280.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhmad SA, Anwar AFTAB, Tahir HAMZA, Mohydin MAHNOOR, Gauhar FA T. I. M. A., Aslam RABIA, ZAIDI KSWH. (2021). Perception of the Educational Environment of Post-graduate Residents in Teaching Hospitals across Pakistan. Pak J Med Health Sci, 15(12), 3218\u0026ndash;3221.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbeje Y, Getinet T, Bekele D, Tadesse M. Evaluation of the learning environment for residency training in St. Paul\u0026rsquo;s Hospital Millennium Medical College. Ethiop Med J. 2018;56(1):11\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4518993/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4518993/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eThe Clinical Learning Environment Review (CLER) is used to evaluate the quality of education and the learning environment for hospital trainees for enhanced patient safety and healthcare quality. The focus areas include practical application of theoretical knowledge, acquisition of clinical skills, and development of problem-solving abilities. Continuous assessment, regular evaluation, and targeted interventions are needed to ensure an environment that supports effective learning and professional development.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e Participants from three residency programs at a Military Hospital in the United Arab Emirates (UAE), were evaluated as per three PHEEM domains with areas of improvement. After study approval, the PHEEM questionnaire was administered online platform after informed consent, with slight modifications for cultural inclusivity and relevance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Data analysis was done using SPSS Statistics Version 22.0. with the Mann-Whitney U test and the Kruskal-Wallis H test, and a p \u0026lt; 0.05. Majority of the trainees were males and Emergency Medicine residents. Perceptions of role autonomy and perceptions of teaching had a mean score of 38.7 (out of 52) and 45.9 (out of 60), respectively, indicating a generally positive outlook, while perception of social support had a mean score of 33.0 (out of 44). Likewise, the total mean study score was 117.7 out of 156. The mean scores for all items ranged from 2.51±1.03 to 3.31±0.58. Areas of improvement were identified for collaboration with other doctors in the same year, while trainees were mostly satisfied with good quality accommodation for junior doctors on call. The results revealed no significant variations in the scores across different strata, although a slightly higher perception of social support was noted among female students. Overall, this study provides insights into the perceptions of the training environment, shedding light on potential areas for improvement in the professional and educational environment at a tertiary care hospital in the Middle East.\u003c/p\u003e\n\u003cp\u003eClinical Trial Number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":" Measuring Clinical Learning Environment across three residency programs using a Postgraduate Hospital Educational Environment Measure (PHEEM) scale at a tertiary care hospital in the United Arab Emirates","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 15:08:28","doi":"10.21203/rs.3.rs-4518993/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7139168f-8ddc-4218-9b25-063d98c201cd","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-13T19:41:23+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 15:08:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4518993","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4518993","identity":"rs-4518993","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}