In April 2018, I had the honor and privilege of being one of 44 invited experts of the Josiah Macy Jr. Foundation to discuss, debate, and develop consensus about recommendations for improving the learning environment in the health professions. I joined with other nurse leaders, as well as professionals from medicine, education, health services administration, dentistry, and public health. Participants were patient advocates, accreditors, learners, clinicians, educators, administrators, and researchers. The conference report (Josiah Macy Jr. Foundation, 2018) offers several advances to accelerate the work around creating effective learning environments. These include a definition of learning environments; a conceptual framework to facilitate a comprehensive approach; a vision for exemplary learning environments; and actionable recommendations for leaders and teachers involved in health professions education. The purpose of this editorial is to provide nurse educators with a synopsis of the recommendations and facilitate further thought about creating exemplary learning environments for our students.
Defining learning environment is significant in describing the key facets of the concept. It is much more than the space in which education occurs. According to consensus of conferees, “Learning environment refers to the social interactions, organization cultures and structures, and physical and virtual spaces that surround and shape participant' experiences, perceptions, and learning” (Josiah Macy Jr. Foundation, 2018, p. 2). Although conversations were focused on health professions education, other disciplines experience challenges with learning environment as well (Gluckman, 2018). Further, throughout the conference, the notion that learning is work and work is learning led to the definition of learners: “In a continuously learning and improving health system, every participant is both a learner and a teacher. Participants include undergraduate and graduate health professions students, trainees, and researchers enrolled in formal educational programs as well as practitioners, educators, administrators, staff, patients, families, and community members” (Josiah Macy Jr. Foundation, 2018, p. 2).
In addition to definitions, a second foundational element to the report recommendations was the adoption of a conceptual framework. The framework was the outcome of a scoping review conducted by Gruppen, Irby, Durning, and Maggio (Josiah Macy Jr. Foundation, 2018). The framework consists of four components that could be visualized as overlapping circles within a Venn diagram: personal component, social component, organizational component, and a physical and virtual component. The personal component consists of what the individual learner brings to the environment. The social component involves the interactions and relationships that influence learning. The organizational component includes the culture, policies, and practice that influence learning. Finally, the physical and virtual component includes the space and resources within which learning takes place. Thus, the learning environment is multifaceted, requiring a variety of strategies at many levels to effect positive change.
Having both a common definition and a conceptual framework provided a solid foundation on which to move forward to achieve the vision of an exemplary learning environment: “Exemplary learning environments prepare, support, and inspire all involved in health professions education and health care to work toward optimal health of individuals, populations, and communities” (Josiah Macy Jr. Foundation, 2018, p. 5). Specific, actionable recommendations were made in six key areas (Josiah Macy Jr. Foundation, 2018):
I. Engaging Academic and Health Care Organization Governance: Governance bodies and executive leadership of organizations responsible for health professions education and health care delivery should ensure positive learning and work environments and be held accountable for allocating the resources necessary to achieve this.
II. Engaging Executive Leadership to Provide Organizational Support: Executive leaders of health professional education and health care organizations should create cultures in which resources, policies, and processes support optimal learning environments across the continuum of health professions education.
III. Creating Physical and Virtual Spaces for Learning: Those in positions of responsibility for learning environments in health professions education and health care organizations should ensure appropriate, flexible, and safe spaces (physical and virtual) for learning.
IV. Providing Faculty and Staff Development: Leaders of health professions education and health care organizations should ensure continuous learning and development opportunities for their faculty and staff to improve learning environments.
V. Promoting Research and Scholarship: Those in positions of responsibility for learning environments should be committed to continuously evaluating, improving, and conducting research on those learning environments.
VI. Setting Policy: Health professions education and health care organization leaders and accreditors should engage in policy advocacy for improvements in health professions learning environments.
Many of the recommendations call on organizational leaders to be accountable for creating positive environments to support learning and patient care. Organizational leaders include board members, executives, managers, and accreditors. While governing boards set expectations, management is responsible for operationalizing the plan, evaluating outcomes, and reporting to the board. Key concepts in creating an effective learning environment include trust, inclusivity, civility, just culture, empowerment, valuing, and supporting interprofessional education and competency development. A specific action for leaders is to “administer policies and procedures that explicate expectations about behaviors reflective of a just, inclusive, and civil culture, as well as interventions with individuals manifesting behaviors that are inconsistent with this culture” (Josiah Macy Jr. Foundation, 2018, p. 8). Clark and Ritter (2018) recently published an exemplar to guide policy development within your own institution.
Nursing faculty have an influence on the environment within classrooms, simulation laboratories, and the virtual environment, as well as within clinical sites and the community. Faculty involved in research may also influence laboratory settings. Six core elements of learning spaces were used to frame recommendations about physical and virtual environments. These include safety (including both physical and psychological), engagement (promoting collaborative learning), connectedness (fostering a sense of belonging), infrastructure (providing resources and leadership), access (providing a variety of resources with consideration of ADA and equity issues), and climate (promoting inclusion). It is important to remember that the expression of inclusivity of an environment can be as subtle as the artwork displayed or as brazen as a tag line (Hansen, 2018). The bottom line is that the learning environment should be welcoming to all learners.
Faculty can certainly focus on engagement, connectedness, and climate. Expert educators have much to offer in regard to professional development. Researchers can make an impact by developing studies with appropriate rigor to advance the design of effective learning environments.
As is characteristic of many reports from Macy conferences in the past, implementation of these recommendations will require a broad-based commitment and transformational change. What will you do to positively influence your learning environments?
Amy J. Barton, PhD, RN, FAAN, ANEF