role of learning environment in clinical learning

Disparities. Recognize Health Care Disparities as a Unique Component of Health Disparities. NLM Health Resources & Services Administration website. Identifying challenges of nursing students in the clinical learning environment could improve training and enhance the quality of its planning and promotion of the students. By engaging new clinicians in comprehensive and systematic QI efforts, CLEs can help these new learners recognize and understand the complexity of factors that contribute to health care disparities—some of which are individual (e.g., explicit or implicit biases) and some of which are systems based (e.g., ineffective processes, breakdowns in communication). To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Copyright © 2020 American Society of Health-System Pharmacists. The Clinical Placement Provider shall assign Clinical Preceptors to Cultural humility is defined as a lifelong process of self-reflection that can inform one’s understanding of cultural differences and how such differences require sensitive approaches to health care.7,8 From a basis of cultural humility, health care organizations can begin to develop cultural competence—defined as “[a] set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.” 9 By focusing on culture, health care organizations can begin the work of ensuring that all patients have an equitable chance at attaining the best possible health outcomes (see box). The report also noted that these differences in quality of care, or health care disparities, were associated with more deaths among minorities than whites.4 These studies are part of the impetus to examine how structures, processes, and behaviors within the US health care system may be contributing to disparities. Purpose: The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. • Understands health care disparities as a unique component of health disparities and understands the potential factors contributing to such disparities. It is the responsibility of higher education institutes (HEI) in partnership with the NHS to prepare nurses and midwives to cope with the complex nature of clinical practice (Burns and Paterson, 2005). Background/Aim. The NCICLE work group identified the following elements as key to providing a solid foundation for engaging new clinicians in efforts to identify and eliminate health care disparities: CLEs with a culture of equity prepare their entire workforce (including new clinicians) to practice cultural humility and to engage in a continuous process of reflection, learning, and improvement that promotes culturally sensitive care. An optimal CLE has a system-wide approach that engages interprofessional staff, clinical educators, and new clinicians in ongoing QI that includes data collection and analysis to inform focused, culturally appropriate QI efforts. Equipped with this information, organizations can develop and implement focused, culturally responsive QI efforts to address the identified disparities.16. Early definition focused on the climate and overall ambiance of the medical education environment (Genn and Harden 1986 ) and highlighted the importance of the climate in which learning occurs (Roff and McAleer 2001 ). Rather, it is intended to serve as a resource that leaders of CLEs may find useful in designing their approach to optimizing learning and care for patients at risk for health care disparities. Translate and Act to Eliminate Any Identified Health Care Disparities. See  Appendix 1 for more information about the purpose of this document and  Appendix 2 for a glossary of terms. By shaping the behaviors of tomorrow’s health care workforce, CLEs can help pave the road towards equity throughout the US health care system. US Office of Disease Prevention and Health Promotion website. In their role as organizations that host clinical training, CLEs have the additional responsibility of preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities—instilling skills and supporting behaviors that clinicians can build throughout their careers. Clinical learning environments involve three key elements: clinical work; learning; and environment. COVID-19 is an emerging, rapidly evolving situation. • Convert QI data on health care disparities into actionable information to be used by clinical educators, staff, and new clinicians. Clinical teachers have an extremely important role in the effectiveness of clinical education in supporting learners, encouraging reflection, and providing constructive and regular feedback. NCICLE takes the view that actions to eliminate health care disparities that result from discrimination in care begin with establishing a culture of equity. At all levels of the CLE, leaders play a central role in developing and sustaining the foundational elements noted above and ensuring they remain a priority throughout the organization. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (.  |  CLEs need to ensure they have clinical educators across professions in place to effectively teach and model efforts to eliminate health care disparities. Please check for further notifications by email. The clinical learning environment is equivalent to a classroom for students during their practicums (Chan, 2004), yet few clinical agencies resemble traditional classrooms. Purpose: To better understand and ultimately eliminate health care disparities, our nation’s health care organizations will need to systematically assess and address the inequities affecting their patient populations. A hospital, ambulatory care clinic, or other health care environment in which new clinicians train. Robust, systems-based and systems-wide approaches to QI are key to health care organizations’ success in addressing health care disparities. New clinicians serve a key role in implementing systems-level process changes. The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. Students’ exposure to clinical learning environment is one of the most important factors affecting the teaching-learning process in clinical settings. Furthermore, as frontline providers who care for vulnerable populations on a daily basis, new clinicians are ideally positioned to provide valuable input to both identify populations at risk and contribute to solutions to eliminate disparities in care and outcomes. every activity that takes place in the ward learning environment. The clinical learning environment is a complex social entity that influences student learning outcomes in the clinical setting. The ward manager therefore determines the learning potential of the ward environment (Lewis 1990:811; Verran 1983:23). The Journal of Continuing Education in Nursing | Hospitals, clinics, and community agencies serve as clinical learning environments (CLEs) for … • Engages in systems-based QI efforts that involve interprofessional teams to eliminate health care disparities within the CLE.  |  The National Academy of Medicine recommends that providers collect and stratify data on the access and use of health care by factors such as patients’ race, ethnicity, socioeconomic status, primary language, sexual orientation, and gender identity.4,14 Health care leaders can then use these stratified data to identify vulnerable populations at risk of or experiencing inadequate care or poorer health care outcomes.15 In addition to the categories noted above, health care organizations may also elect to collect or stratify data according to various subpopulations at risk—such as migrant populations or patients with disabilities—that help to further distinguish or identify disparities in care, especially in situations when the majority of the patient population is deemed vulnerable. • Understands how the CLE continually identifies health disparities and health care disparities among its patient population. With better understanding of attributes comprising the clinical learning environment, nursing education programmes and healthcare agencies can collaborate to create meaningful clinical experiences and enhance student preparation for the professional nurse role. Across the United States, health care disparities persist, while the overall quality of health care continues to improve.1,2 These disparities occur across many dimensions, including but not limited to race and ethnicity, socioeconomic status, sexual orientation, and gender identity.1-3 For example, the National Academy of Medicine (formerly the Institute of Medicine) 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care concluded that minority patients generally receive lower quality health care than whites in the United States, regardless of their insurance status or their ability to pay for care. Treating individuals in the same manner irrespective of their needs and requirements. BACKGROUND: Clinical facilities are essential components not only of health care delivery systems, but also of health care education programs. [1 ,8 9] Negative experi-ences in the clinical setting often hindered learning and had uality Clinical Learning Environment Each clinical nurse/midwife manager has a professional responsibility to ensure that the facilitating factors for providing a quality clinical learning environment are supported, to enable the student learn the practice of nursing/midwifery. Teaching in the clinical environment is defined as teaching and learning focused on, and usually directly involving, patients and their problems (Spencer 2003). For the purposes of this document, the NCICLE work group identified and categorized responsibilities according to 3 types of leaders (i.e., executive, QI, and clinical education) who are central to setting organizational priorities, establishing a QI culture, and ensuring optimal training for new clinicians (Table 1). • Understands the QI tools and methods employed by the CLE for analyzing health care disparities among its patient population. Efforts may include training in cultural humility and cultural competency, education about the organization’s vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities. Please enable it to take advantage of the complete set of features! Ecological psychology and workplace learning emphasize that social interaction is facilitated through affordances in the learning/working environment (tools, scaffolded relationships, tasks, language, concepts) and the active engagement of learners (through their agency, engagement and emerging autonomy) (Billett, 2001). • Prioritize training that will help new clinicians develop cultural humility and awareness of implicit and explicit bias at the individual and institutional level. Of note, this framework is not designed to propose a specific curriculum or to suggest regulatory action. A supportive clinical learning environment (CLE) is vital to the success of the teaching learning process. Students training in a clinical setting as well as individuals transitioning from a health profession’s education environment to a clinical learning environment (e.g., physician residents, nurses, pharmacists, etc., who are new to practice). Published by Oxford University Press on behalf of the American Society of Health-System Pharmacists 2019. A supportive clinical learning environment (CLE) is vital to the success of the teaching learning process. USA.gov. • Demonstrates a commitment to the CLE’s culture of equity through learning, skill development, practice, and reflection to provide equitable, high-quality health care in the context of cultural humility. Two critical aspects of the learning environment, when viewed through a psychology lens are (1) constructs from psychology relevant to learning, such as cognitive load theory and learner self-efficacy; and (2) psychological attributes of the context in which learning occurs such as … The frameworks used to systematically improve the ways care is delivered to patients.17. “A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.” 9 Cultural humility. What are health disparities and health equity? We need to be clear, Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis, Disparities in health and health care: five key questions and answers, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, The Commission to End Health Care Disparities, Collecting and Using Race, Ethnicity and Language Data in Ambulatory Settings: A White Paper With Recommendations From The Commission to End Health Care Disparities, Mosby’s Dictionary of Complementary and Alternative Medicine, Module 4. Published by Oxford University Press on behalf of the American Society of Health-System Pharmacists 2019. With foundational elements in place, CLEs are better positioned to prepare new clinicians with the skills and desired behaviors needed to effectively engage in systems-based QI to identify and eliminate health care disparities. For example, FitzGerald and Hurst found that implicit bias was negatively correlated with quality of care indicators.5 In addition, a 2017 study by the Harvard T.H. “[The] attainment of the highest level of health for all people. Participate in Analysis of Health Care Disparities. ©2019 National Collaborative for Improving the Clinical Learning Environment. By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system. The authors have declared no potential conflicts of interest. QI acknowledges human fallibility and recognizes that, often, negative outcomes are the result of poorly designed systems.17,18, Health care disparities are often a systems-level issue that, to be addressed effectively, necessitate a commitment to continuous QI throughout all areas of the organization. It is also where the Criteria 2.1. Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities. With this infrastructure in place, organizations can begin to engage new clinicians in QI focused on health care disparities, including the steps of (1) collecting and analyzing data to identify health care disparities and the CLE’s vulnerable patient populations; (2) using stratified data to develop focused, culturally appropriate QI efforts; (3) communicating QI findings to all relevant CLE staff, including new clinicians; (4) using QI findings to inform changes needed to eliminate health care disparities; and (5) conducting ongoing analyses to determine if changes resulted in the desired outcome and modifying the efforts as needed (see Table 2). This document highlights several key concepts: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. New Clinician Skills and Associated Desired Behaviors Needed for Engaging in Quality Improvement Efforts to Eliminate Health Care Disparities. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Many nursing students perceive their clinical learning environment as anxiety and stress provoking. Early and frequent clinical experiences should be planned and integrated in curricula. Engaging new clinicians is a key element of any systems-based approach, as new clinicians will shape the future of health care delivery. For leaders of CLEs, a key part of this commitment is preparing and engaging their clinical workforce in efforts to eliminate disparities in health care. Differences between groups in health insurance coverage, access to and use of care, and quality of care received. • Continually demonstrate commitment to eliminating health care disparities (e.g., role modeling, priority setting, supporting QI projects focused on health care disparities, ongoing communication, continuous learning and improvement, integration of new clinicians). Search for other works by this author on: Marie Chisholm-Burns, Pharm.D., M.P.H., M.B.A., FCCP, FASHP, FAST, College of Pharmacy and College of Medicine, University of Tennessee Health Science Center, Clinical Learning Environment Review Program, Accreditation Council for Graduate Medical Education, Address correspondence to Ms. Passiment (, Agency for Healthcare Research and Quality, 2016 National Healthcare Quality and Disparities Report, Lesbian, gay, bisexual, and transgender health, US Office of Disease Prevention and Health Promotion website, The effects of training institution practice costs, quality, and other characteristics on future practice, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Implicit bias in healthcare professionals: a systematic review, Cultural humility is the first step to becoming global care providers, Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Practical training has a special role to play in her learning. Hafferty described three components of the educational milieu: (1) the stated, intended, and formally offered and endorsed curriculum; (2) an unscripted, predominantly ad hoc and highly inter-personal form of teaching and learning that takes place among or between faculty and students (the informal curriculum); and (3) a set of influences that function at the level or organizational structure and … • Work closely with the QI leadership to design and implement programs for optimal clinical learning across professions in the area of QI focused on eliminating health care disparities. Phillips RL, Petterson SM, Bazemore AW et al. Clipboard, Search History, and several other advanced features are temporarily unavailable. • Mentor new learners in systems-based, interprofessional QI efforts focused on eliminating health care disparities. To be an effective nurse educator, RNs learned through programs such as Duquesne University’s MSN … It is focused on real problems in the context of professional practice. Professional thinking, behaviour, and attitudes are “modelled” by teachers. Efforts may include training in cultural humility and cultural competency, education about the organization's vulnerable populations, and continuous interprofessional experiential learning through comprehensive, systems-based QI efforts focused on eliminating health care disparities.  |  The term learning environment can refer to an educational approach, cultural context, or physical setting in which teaching and learning occur. In order to maximise the learning potential of the clinical environment, it is important that Baretta R Casey, M.D., M.P.H., FAAFP, Baretta R Casey, M.D., M.P.H., FAAFP. Learners are motivated by its relevance and through active participation. Hospitals, ambulatory care sites, and other CLEs in which new clinicians train have an important role in preparing and supporting the clinical workforce to provide high-quality care for vulnerable populations. The Nursing and Midwifery Council (2008) has defined mentors a… Driver diagram outlining the clinical learning environment’s role in supporting new clinical engagement in quality improvement to eliminate health care disparities. NIH Summary: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. “A particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage.” 10. To guide CLEs in engaging new clinicians in systems-based QI efforts to eliminate health care disparities, the NCICLE work group developed a framework that includes foundational elements, the role of leadership in supporting these foundational elements, and important skills and behaviors that prepare new clinicians to participate as members of interprofessional teams to eliminate health care disparities and provide equitable care. Summary: Kirk JK, D’Agostino RB, Bell RA et al. National efforts have substantially raised the visibility of health care disparities in the United States.1,2,4,9 Regardless of this visibility, disparities in care continue to persist throughout the US health care system, leading to poorer health outcomes for vulnerable patient populations. • Uses a systems- and evidence-based approach to determine how patient safety events can guide system improvement. In developing a systems-based approach to engaging new clinicians in QI to eliminate health care disparities, CLE leaders may consider using tools—such as a driver diagram—to create a shared vision of their aims and the actions needed to achieve those aims. In today’s language, one might say the teacher is still “the adult in the room”, in that he or she knows what needs to happen for learning to take place. • Foster partnership with clinical C-suite to inform strategic goals in the area of health care disparities. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. The aim of this study was to investigate the role of the ward manager in creating a conducive clinical learning environment for nursing students. Engaging new clinicians in systems-based QI early in their careers benefits both the new learners and the organization. Chan School of Public Health, the Robert Wood Johnson Foundation, and National Public Radio showed that discrimination is an important barrier to equity in US health care.6 Of the 3453 people polled in the study, 32% of Black Americans, 23% of Native Americans, and 20% of Latinos reported experiencing discrimination when going to a doctor or health clinic, as did 18% of the women and 16% of the lesbian, gay, bisexual, transgender, and queer individuals participating in the survey.6. He saw the teacher’s role as that of coach and facilitator who still maintained the ultimate responsibility for ensuring an effective educational environment. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. The original is available at https://www.ncicle.org/health-care-disparities. Approaches to Quality Improvement, Quality Chasm: A New Health System for the 21st Century, Centers for Medicare and Medicaid Services, Defining and Using Aims and Drivers for Improvement. The National Collaborative for Improving the Clinical Learning Environment Quality Improvement: Focus on Health Care Disparities Work Group, National Collaborative for Improving the Clinical Learning Environment, Chicago, IL. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Have you ever noticed what the teacher did to make learning more inviting? For hospitals, medical centers, and clinical care providers, a key part of ensuring health equity is to have a systematic approach to identifying and eliminating health care disparities related to the care provided by their organization. Align With Culture of Equity and Commitment to Ongoing QI. These tools also serve as useful guides for monitoring and assessing progress toward the aims.19Figure 1 provides an example of how CLEs might organize the guidance offered in this document into a set of aims, primary drivers, and secondary drivers. An important component of this culture is the expectation of cultural humility. Learning in the clinical environment has many strengths. Many nursing students perceive their clinical learning environment as anxiety and stress provoking. To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Information about the purpose of this culture is the expectation of cultural humility awareness... Ties ” [ 7 ] among its patient population processes to identify and health..., FAAFP Press on behalf of the teaching learning process teams to eliminate health care disparities coverage, access and. 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