How do medical students define a Health Promoting Learning Environments?

Authors

  • Rachel Joffe University of Alberta
  • Veronica Oczkowski University of Alberta
  • Diana Le University of Alberta
  • Melanie Lewis University of Alberta
  • Victor Do University of Alberta

DOI:

https://doi.org/10.36834/cmej.80123

Abstract

Background: Medical students in Canada report significantly higher rates of suicidal ideation, psychological stress, as well as mood and anxiety disorders, compared to age matched general population. We are still early in the process of having a comprehensive approach to learner wellbeing that centers around health promoting learning environments (HPLE) - focusing on more systemic actions as guided by the international Okanagan Charter. To move forward, we need to further understand what learners, faculty and staff view as critical components in an HPLE and explore how we can best advance efforts to create and embed HPLEs in medical education. The objectives of this study were to elucidate how medical students define an HPLE and what medical students perceive as the main barriers and facilitating factors to developing and fostering HPLEs.

Methods: We undertook an exploratory qualitative study using virtual semi-structured interviews of how medical students define an HPLE and the facilitators and barriers of this. We used thematic analysis to review all transcripts with ongoing iterative analysis. Final themes were agreed on consensus.

Results: We interviewed 14 medical students from all years at the University of Alberta. We identified four overarching themes which serve as important components of an HPLE including that HPLEs have foundational characteristics of respect, transparency, and open communication. Developing HPLEs require multi-pronged approaches that starts with ensuring basic needs are met and empowering learners to make health promoting choices. Learners identified that a culture of wellbeing is driven by wellbeing centered leadership. A safe space to take an active role in influencing their environment help learners thrive.

Conclusions: Our study focused on elucidating medical student perspectives on factors that contribute to and foster a health promoting learning environment. Our findings can inform on systemic efforts to embed wellbeing into medical education in Canada.

References

1. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences and solutions. J Intern Med. 2018 Jun;283(6):516-29. https://doi.org/10.1111/joim.12752

2. Shanafelt TD, West CP, Sinsky C, et al. Changes in burnout and satisfaction with work-life integration in physicians and the general US working population between 2011 and 2017. InMayo Clinic Proceedings 2019 Sep 1 (Vol. 94, No. 9, pp. 1681-1694). Elsevier. https://doi.org/10.1016/j.mayocp.2018.10.023

3. Maser B, Danilewitz M, Guérin E, Findlay L, Frank E. Medical student psychological distress and mental illness relative to the general population: a Canadian cross-sectional survey. Acad Med. 2019 Nov 1;94(11):1781-91. https://doi.org/10.1097/ACM.0000000000002958

4. Wilkes C, Lewis T, Brager N et al. Wellbeing and mental health amongst medical students in Canada. Internat Rev Psych. 2019 Nov 17;31(7-8):584-7. https://doi.org/10.1080/09540261.2019.1675927

5. Jaffri S, Kassas K, Farjalla M, Yousuf DJ. Mental health and wellness of medical students in Ontario–A mixed methods approach. Med Teach. 2024 Oct 1:1-8. https://doi.org/10.1080/0142159X.2024.2407965.

6. Dyrbye LN, West CP, Satele D, et al. Burnout among US medical students, residents, and early career physicians relative to the general US population. Acad Med. 2014 Mar 1;89(3):443-51. https://doi.org/10.1097/ACM.0000000000000134

7. Compton MT, Carrera J, Frank E. Stress and depressive symptoms/dysphoria among US medical students: results from a large, nationally representative survey. J Nervous Mental Dis. 2008 Dec 1;196(12):891-7. https://doi.org/10.1097/NMD.0b013e3181924d03

8. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016 Jan;50(1):132-49. https://doi.org/10.1111/medu.12927

9. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Annals surg. 2010 Jun 1;251(6):995-1000. https://doi.org/10.1097/SLA.0b013e3181bfdab3

10. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. Jama. 2009 Sep 23;302(12):1294-300. https://doi.org/10.1001/jama.2009.1389

11. Thomas MR, Dyrbye LN, Huntington JL, et al. How do distress and well-being relate to medical student empathy? A multicenter study. J Gen Intern Med. 2007 Feb;22:177-83. https://doi.org/10.1007/s11606-006-0039-6

12. Dyrbye LN, Massie FS, Eacker A, et al. Relationship between burnout and professional conduct and attitudes among US medical students. Jama. 2010 Sep 15;304(11):1173-80. https://doi.org/10.1001/jama.2010.1318

13. Lam, Betson, Wong, Wong. A prospective analysis of stress and academic performance in the first two years of medical school. Med Educ. 1999 Apr;33(4):243-50. https://doi.org/10.1046/j.1365-2923.1999.00294.x

14. Dyrbye LN, Thomas MR, Harper W, et al. The learning environment and medical student burnout: a multicentre study. Med Educ. 2009 Mar;43(3):274-82. https://doi.org/10.1111/j.1365-2923.2008.03282.x

15. Dunham L, Dekhtyar M, Gruener G, et al. Medical student perceptions of the learning environment in medical school change as students transition to clinical training in undergraduate medical school. Teach Learn Med. 2017 Oct 2;29(4):383-91. https://doi.org/10.1080/10401334.2017.1297712

16. Holt MC, Roff S. Development and validation of the anaesthetic theatre educational environment measure (ATEEM). Med Teach. 2004 Sep 1;26(6):553-8. https://doi.org/10.1080/01421590410001711599

17. Gruppen LD, Irby DM, Durning SJ, Maggio LA. Conceptualizing learning environments in the health professions. Acad Med. 2019 Jul 1;94(7):969-74. https://doi.org/10.1097/ACM.0000000000002702

18. MacLeod RD, Parkin C, Pullon S, Robertson G. Early clinical exposure to people who are dying: learning to care at the end of life. Med Educ. 2003 Jan;37(1):51-8. https://doi.org/10.1046/j.1365-2923.2003.01412.x

19. Wear D. “Face-to-face with it”: medical students' narratives about their end-of-life education. Acad Med. 2002 Apr 1;77(4):271-7. https://doi.org/10.1136/postgradmedj-2012-131474

20. Orom H, Semalulu T, Underwood III W. The social and learning environments experienced by underrepresented minority medical students: a narrative review. Acad Med. 2013 Nov 1;88(11):1765-77. https://doi.org/10.1097/ACM.0b013e3182a7a3af

21. Mavis B, Sousa A, Lipscomb W, Rappley MD. Learning about medical student mistreatment from responses to the medical school graduation questionnaire. Acad Med. 2014 May 1;89(5):705-11. https://doi.org/10.1097/ACM.0000000000000199

22. Teshome BG, Desai MM, Gross CP, et al. Marginalized identities, mistreatment, discrimination, and burnout among US medical students: cross sectional survey and retrospective cohort study. BMJ. 2022 Mar 22;376. https://doi.org/10.1136/bmj-2021-065984

23. Mantri S, Jooste K, Lawson J, Quaranta B, Vaughn J. Reframing the conversation around physician burnout and moral injury: “we’re not suffering from a yoga deficiency.” Permanente J. 2021;25. https://doi.org/10.7812/TPP/21.005

24. Charter O. Okanagan Charter: An international charter for health promoting universities and colleges. InInternational Conference on Health Promoting Universities & Colleges: Kelowna, BC, Canada 2015. Available from: https://open.library.ubc.ca/cIRcle/collections/53926/items/1.0132754

25. Olsson TM, Broberg M, Frisk S, et al. Health‐promoting learning environments in higher education: a scoping review of structural interventions to protect student mental health. Euro J Educ. 2024:e12772. https://doi.org/10.1111/ejed.12772

26. Do V, Lewis M, Goldstein C, Sonnenberg LK. Fostering a health-promoting learning environment in medical education: adapting the Okanagan Charter for administrators and medical educators. Acad Med. 2023 Jun 1;98(6):672-9. https://doi.org/10.1097/ACM.0000000000005159

27. Watling C, Ginsburg S, LaDonna K, Lingard L, Field E. Going against the grain: an exploration of agency in medical learning. Med Educ. 2021 Aug;55(8):942-50. https://doi.org/10.1111/medu.14532

28. Richards J, Sweet L, Billett S. Preparing medical students as agentic learners through enhancing student engagement in clinical education. Asia-Pacific J Cooperative Educ. 2013;14(4):251-63.

29. Neufeld A. Moving the field forward: using self-determination theory to transform the learning environment in medical education. Teach Learn Med. 2023 Jul 8:1-6. https://doi.org/10.1080/10401334.2023.2235331

30. Ten Cate OT, Kusurkar RA, Williams GC. How self-determination theory can assist our understanding of the teaching and learning processes in medical education. AMEE guide No. 59. Med Teach. 2011 Dec 1;33(12):961-73. https://doi.org/10.3109/0142159X.2011.595435.

31. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qual Res Psychol. 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

32. Roulston, K. Considering quality in qualitative interviewing. Qual Res. 2010;10(2), 199–228. https://doi.org/10.1177/1468794109356739

33. Nowell LS, Norris JM, White DE, Moules NJ. Thematic analysis: striving to meet the trustworthiness criteria. Internat J Qual Meth. 2017;16(1), 1-13. https://doi.org/10.1177/1609406917733847

34. Low J. A pragmatic definition of the concept of theoretical saturation. Sociol focus. 2019 Apr 3;52(2):131-9. https://doi.org/10.1080/00380237.2018.1544514

35. Shan S, Li C, Shi J, Wang L, Cai H. Impact of effective communication, achievement sharing and positive classroom environments on learning performance. Systems Res Behav Sci. 2014 May;31(3):471-82. https://doi.org/10.1002/sres.2285

36. Watson S. Closing the feedback loop: ensuring effective action from student feedback. Tertiary Educ Manag. 2003 Jun;9(2):145-57. https://doi.org/10.1080/13583883.2003.9967099

37. Li‐Sauerwine S, Rebillot K, Chung AS, Coates WC, Shah S, Yarris LM. Moving beyond personal factors: A national study of wellness interventions in emergency medicine residency programs. AEM Educ Training. 2021 Oct;5(4):e10690. https://doi.org/10.1002/aet2.10690

38. Edmondson EK, Kumar AA, Smith SM. Creating a culture of wellness in residency. Acad Med. 2018 Jul 1;93(7):966-8. https://doi.org/10.1097/ACM.0000000000002250

39. Engineer A, Gualano RJ, Crocker RL, et al. An integrative health framework for wellbeing in the built environment. Building Enviro. 2021 Nov 1;205:108253. https://doi.org/10.1016/j.buildenv.2021.108253

40. Titus S, Roman NV. Predictors of student agency: the relationship between student agency, learning support and learning experiences in an interprofessional health science faculty. J Interprofess Care. 2019 Apr 26. https://doi.org/10.1080/13561820.2019.1596072

41. Manyukhina Y, Wyse D. Learner agency and the curriculum: A critical realist perspective. Curriculum J. 2019 Jul 3;30(3):223-43. https://doi.org/10.1080/09585176.2019.1599973

42. Stanton A, Zandvliet D, Dhaliwal R, Black T. Understanding students' experiences of well-being in learning environments. Higher Educ Studies. 2016;6(3):90-9. https://doi.org/10.5539/hes.v6n3p90

43. Kapadia SJ. Perspectives of a 2nd-year medical student on ‘Students as Partners’ in higher education–What are the benefits, and how can we manage the power dynamics? Med Teach. 2021 Apr 3;43(4):478-9. https://doi.org/10.1080/0142159X.2020.1779922

44. Neufeld A, Mossière A, Malin G. Basic psychological needs, more than mindfulness and resilience, relate to medical student stress: a case for shifting the focus of wellness curricula. Med Teach. 2020 Dec 1;42(12):1401-12.

45. Shanafelt T, Trockel M, Rodriguez A, Logan D. Wellness-centered leadership: equipping health care leaders to cultivate physician well-being and professional fulfillment. Acad Med. 2021 May 1;96(5):641-51. https://doi.org/10.1097/ACM.0000000000003907

46. Shanafelt TD, Makowski MS, Wang H et al. Association of burnout, professional fulfillment, and self-care practices of physician leaders with their independently rated leadership effectiveness. JAMA network open. 2020 Jun 1;3(6):e207961-. https://doi.org/10.1001/jamanetworkopen.2020.7961

47. Squires V, London C. The Okanagan Charter: evolution of health promotion in Canadian higher education. Can J Higher Educ. 2021;51(3):100-14. https://doi.org/10.47678/cjhe.vi0.189109

48. Hoert J, Herd AM, Hambrick M. The role of leadership support for health promotion in employee wellness program participation, perceived job stress, and health behaviors. Amer J Health Promo. 2018 May;32(4):1054-61. https://doi.org/10.1177/0890117116677798

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Published

2025-04-02

How to Cite

1.
Joffe R, Oczkowski V, Le D, Lewis M, Do V. How do medical students define a Health Promoting Learning Environments? . Can. Med. Ed. J [Internet]. 2025 Apr. 2 [cited 2025 Apr. 9];. Available from: https://journalhosting.ucalgary.ca/index.php/cmej/article/view/80123

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