The Council on Medical Student Education in Pediatrics continues the series about skills of, and strategies used by great clinical teachers. Great clinical teachers recognize that many things influence students’ learning, including what they teach, how they teach, and where they teach.1,2 “Where” refers to the learning environment. Although the term “environment” may conjure visions of trees, snow-capped mountains, and rain, the “learning environment” refers to the setting in which the curriculum exists. The learning environment includes the physical, social, and psychological context in which students learn and the overall atmosphere or culture pervading the setting where students and clinical teachers work and learn together.3,4 Although the learning environment of an institution is greatly influenced at the organizational level, this article will focus on elements under the control of individual teachers. We describe practical ways busy clinical teachers can foster a positive learning environment.
Why a Positive Learning Environment Is Important
A positive learning environment helps students succeed,5 affects their moral development,6 and models a humanistic approach to medicine.7 Recently, the Association of American Medical Colleges released a statement on the optimal learning environment.8 However, for decades, great clinical teachers have known that the learning environment affects ethical and personal development.9 Orienting students leads to improved preparedness for clinical work,10 and encouraging students to be active participants in the learning process leads to enhanced learning.11 In addition, the presence of exemplary role models enhances learning.12
How to Create a Positive Learning Environment
Clinical teachers foster a positive learning environment in many practical ways (Table 1). In pediatrics, students worry about “breaking” a child, “dropping a baby,” “hurting” a child, not knowing how to relate to children, and not knowing how to examine “such a small baby” or calm a baby down.13 They also worry about the parents’ reactions, dealing with “2 things at once” (the parent and the child), “moms yelling” at them, and not knowing what to say to parents or how to answer their questions.13
Teachers have a role in addressing these concerns explicitly, giving students practical tips in communicating with patients and families, and examining patients in developmentally appropriate ways. Ideally, the conversation occurs at the beginning of a teacher-student interaction (whether the start of a shift in the emergency department or the first day of a multiweek experience). Great clinical teachers provide practical tips about working with pediatric patients and families, such as being flexible with the order of the physical exam, adjusting the history and physical exam to the developmental age of the child, using parents as allies in the physical exam, talking to patients about their interests, getting down to the patient’s level, and appreciating the fun and playfulness of this patient population.13
We have organized, in a typical timeline, actions great clinical teachers take to create a positive learning environment, from before students arrive to the end of their clinical experience.
Before Students Arrive
Fostering a positive learning environment begins before students arrive to work with a teacher. Although administrative logistics are not a highlight of this article, knowing the course or clerkship director and how to contact him or her with questions or concerns is important. Clarifying the clerkship director’s expectations for students in clinical settings and criteria for assessment and grading prepares the teacher to explain these parameters to students when they arrive, so students know from the beginning the basis for assessment in the clinical setting.
Before they arrive, students need to be oriented regarding the location of the clinical experience and expectations such as when to arrive, how to prepare, and what to bring.10 Students should be made aware if they are supposed to be in different locations on different days (for instance, for school visits, multidisciplinary meetings, or grand rounds). Alerting students about the medical tools they do or do not need to bring allows the student to arrive prepared. Letting students know the types and ages of patients being seen and conditions likely encountered permits advance reading in developmental or diagnostic principles so that the student can demonstrate knowledge and be slightly more comfortable in a potentially scary setting.
Your Time With the Student
Upon beginning a clinical experience, students need to be oriented about expectations (the teacher’s and the clerkship director’s), objectives, logistics (eg, where to store personal items, how to access the internet), and organization of the rotation (eg, whether students will see patients initially on their own, how much time should be taken per patient).10 Students should be introduced to all members of the health care team; staff and nurses need to be introduced to students and oriented to their roles so that students’ purpose on the team is clear.14
Teachers who role-model respect and concern for students’ well-being and learning set the stage for success.12 Creating a safe environment in which students can take risks (such as expanding the differential diagnoses), stretch their limits, learn, and grow is important.4 A safe learning environment allows learners to acknowledge their attitudes and beliefs, knowledge gaps, uncertainty, and mistakes. Humility can be a powerful tool and requires open-mindedness, a willingness to consider other views, and a readiness to learn from other perspectives. Some teachers may be reluctant to say “I don’t know” or “let’s look it up” for fear of appearing incompetent. A teacher’s willingness to admit ignorance is a powerful way to model openness to lifelong learning and build a safe learning environment for everyone.12
Teachers can build a positive learning environment by avoiding interrupting students before they finish presenting a case and using good eye contact, a supportive tone of voice, and appreciative facial expressions to create students’ sense of safety.15 Humor, when used occasionally, can motivate attention and, more importantly, can foster a safe learning environment by diffusing anxiety and tension.16
During interactions with students, several important concepts contribute to a positive learning environment: direct observation,17 formative feedback,18 and open communication.14 In addition, students generally want to progress during each clinical placement, and they appreciate when teachers create an environment that facilitates progress by providing targeted feedback, opportunities to practice the skills about which they received feedback, and then opportunities to demonstrate progress to their teachers.19 While together with the student (whether during an emergency department shift, a few days on the wards, or several months in clinic) teachers can enhance the learning environment by being positive role models12 and treating students as meaningful members of the health care team.14
At the Completion of Your Time With Students
Upon completion of a shift or rotation, great clinical teachers reflect with their students to review learning points and logistical issues.20 Importantly, great clinical teachers provide relevant and meaningful summative feedback and offer concrete suggestions on how students may improve.18 The great clinical teacher also asks for feedback, for example, by asking, “how could I have made this experience more effective for you?” Discussing how concepts learned by students will enhance their future medical practice will complete the learning cycle in a positive environment.
Great clinical teachers take deliberate actions to foster a positive learning environment. They recognize that making the clinical setting feel safe, welcoming, and open will lead to greater learning and enhanced patient care. They appreciate that the students will, in the not-too-distant future, be their colleagues, and they treat them with the respect and support they deserve. Ultimately, the learning environment enriches the effect of the teacher.
- Accepted April 22, 2015.
- Address correspondence to Susan L. Bannister, Department of Pediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail NW, Calgary, Alberta, Canada T3B 6A8. E-mail:
Dr Bannister conceptualized and drafted the initial manuscript; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding was secured for this study.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Bannister SL
- 8.↵AAMC Statement on the Learning Environment. Washington, DC: AAMC; 2014. Available at: https://www.aamc.org/initiatives/learningenvironment/. Accessed April 3, 2015
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- Copyright © 2015 by the American Academy of Pediatrics