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Year : 2008  |  Volume : 21  |  Issue : 3  |  Page : 32

Factors Adversely Affecting Student Learning in the Clinical Learning Environment: A Student Perspective

1 Maastricht University, Department of Educational Development & Research, Maastricht, Netherlands
2 Academic Hospital Maastricht, Institute for Clinical Education, Maastricht; Present position: Maxima Medical Centre, Veldhoven, Netherlands
3 Institute for Medical Education, Maastricht, Netherlands

Date of Submission27-Apr-2007
Date of Acceptance30-Sep-2008
Date of Web Publication19-Dec-2008

Correspondence Address:
DHJM Dolmans
P.O. Box 616, 6200 MD Maastricht
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Source of Support: None, Conflict of Interest: None

PMID: 19967634


Purpose: To investigate, from the students' perspective, factors that may adversely affect student learning in the clinical environment.
Method: Medical students evaluated the perceived effectiveness of the clinical learning environment at the end of various clerkship rotations, such as surgery, gynaecology, paediatrics, ophthalmology. After each clerkship students answered a standard questionnaire containing closed-ended questions about supervision, patient contacts, organisation, learning effectiveness and the learning climate, as well as one open-ended question about the clerkship-site's perceived weaknesses. Because supervision is crucial to the quality of clerkships but often lacking, we compared clerkship-sites with relatively low and high ratings on supervision and analysed students' comments on the weaknesses of their clerkship-sites.
Results: Factors that students perceived were inhibiting learning were too few opportunities for students to examine patients independently and lack of time for supervision. In addition, lack of observation, insufficient feedback, negative attitudes of the staff towards students and teaching, the presence of too many students at one time, too few educational sessions, and poor organisation were mentioned as perceived weaknesses in open-ended comments.
Conclusions: Based on these students' perceptions, effective clerkships should present students with patients with a variety of health problems who can be examined both independently and with supervision. Continuity of supervision is important and can be addressed by assigning a teacher or mentor to each student.

How to cite this article:
Dolmans D, Wolfhagen I, Heineman E, Scherpbier A. Factors Adversely Affecting Student Learning in the Clinical Learning Environment: A Student Perspective. Educ Health 2008;21:32

How to cite this URL:
Dolmans D, Wolfhagen I, Heineman E, Scherpbier A. Factors Adversely Affecting Student Learning in the Clinical Learning Environment: A Student Perspective. Educ Health [serial online] 2008 [cited 2022 Jan 28];21:32. Available from:


Clinical teaching occurs in the context of a fast-paced and dynamic environment, with clinician-teachers struggling to handle the dual roles of patient care and teaching (Irby & Bowen, 2004). The clinical environment is characterised by multiple tensions. Hofman and Donaldson (2004) described three major contextual tensions that affect teaching and learning in the clinical environment: 1) patient census, i.e. the number of patients, the types of illnesses, and the pace at which patients move through the healthcare system; 2) the pace at which ongoing patient care activities are taking place; and 3) the multiple and conflicting responsibilities of the team, i.e. the challenge of appropriately allocating time to teaching, learning, patient care and other commitments. Financial pressures on clinical teaching institutions and the growing number and types of learners further complicate the clinical training environment (Roth et al., 2001). Given the complexity, conflicting roles and tensions of the clinical setting, the challenge facing clinician-teachers is to create a high quality learning environment for students.

Several factors have been shown to influence the effectiveness of student learning in a clinical environment; the mix of patients seen by students, the supervision they receive, organisational quality, and the number of students simultaneously learning at the site (Dolmans et al., 2002a, Durak et al., 2008). Supervision appears to be the key to the success of clerkships. Kilminster and Jolly (2000) defined supervision as “the provision of monitoring, guidance and feedback on matters of personal, professional and educational development in the context of the doctor’s care of patients”. Helpful supervisory behaviours include direct guidance on clinical work, linking theory and practice, and offering feedback and role modelling. In students’ perceptions, providing observation and constructive feedback are key features of effective clinical learning experiences (Van der Hem-Stokroos et al., 2003). Feedback is best given regularly during and after interactions between students and patients and at the midpoint of clinical clerkships.

By giving feedback and encouraging students to reflect, supervisors can have a positive affect on learning (Irby & Bowen, 2004). Feedback and reflection are basic teaching methods of the clinical setting; unfortunately, they are generally underused (Branch & Paranjape, 2002). Studies have found that supervision is considered important and effective but that it occurs too infrequently; consequently, learning in the clinical environment is haphazard and varies from student to student (Daelmans et al., 2004; Grant et al., 2003; O Neill et al., 2006; Van der Hem-Stokroos et al., 2001).

The aim of this study was to investigate the factors students perceive as having a detrimental effect on their learning in clinical settings. Students’ perceptions are important because they provide insight into the factors that hinder learning as novices in clinical practice and can suggest approaches for improvement. The research question is: What factors do students perceive adversely affect their learning during clinical clerkships?


Setting and Subjects

At Maastricht Medical School, The Netherlands, undergraduate medical students are generally from Holland and matriculate at age 18. They receive clinical training during clerkships in the last period of year four and in years five and six of their curriculum, during clerkships in the inpatient wards and outpatient clinics in the Academic Hospital Maastricht or one or more of 13 regional hospitals. During clerkships students are supervised by both consultants and residents. They are assessed at the end of each clerkship by a test and their performance in practice is assessed by means of several global judgements.

This study involved approximately 350 students undertaking 3- to 12-week rotations in 2004 in Internal Medicine, Surgery, Obstetrics/Gynaecology, Paediatrics, Neurology, Ophthalmology, Ear, Nose and Throat (ENT), and Dermatology. Students participating in other rotations–Psychiatry, Social Medicine, and Family Medicine–were not included in this study, because they routinely complete a different end-of–rotation evaluation instrument than that used by the included disciplines.


At the end of each rotation students were asked to complete a questionnaire on which they were to assess, on a scale from 1 (lowest) to 10 (highest), the working climate, organisation, learning effectiveness and supervision for the clerkship and site they had just completed. In addition to these general items, the questionnaire contained five detailed items addressing the quality of supervision and five addressing patient contacts, which were rated on a five-point scale (1=disagree; 5=agree). The items on the questionnaire were derived from the literature on effective teaching and learning during clerkship rotations and were selected based on their relevance to our curriculum and training sites, with input from staff and students. Students’ responses were anonymous. A previous exploratory factor analysis of responses on the 10 detailed items revealed two factors with an Eigen value greater than 1: supervision (items 1-5) and patient contacts (items 6-10), with alpha coefficients of 0.83 and 0.81, respectively. Two scales with these 10 items were validated in an earlier study (Dolmans et al., 2002b) and were included in the present study. The questionnaire also contained an open-ended item asking students to comment on what they saw as the strengths and weaknesses of the clerkship. Because we were interested in factors perceived as adversely affecting learning during clerkships, our analyses focused on students’ comments about weaknesses. Appendix I summarises the questionnaire items included in the analysis. We used a 10-point scale for overall items and a 5-point scale for specific items.

Data analysis

All analyses were conducted at the level of individual student ratings. In total 1425 completed questionnaires with ratings were available from approximately 350 different students. The response rates for students completing clerkships were 81% for internal medicine, 45% for surgery, 90% for gynaecology, 75% for paediatrics, 68% for neurology, 81% for ophthalmology and 41% for ear, nose and throat. Because student assessments were anonymous, we could not determine exactly how many different students from each year were involved in each discipline and clerkship-site. We know, however, that at least seven student responses were available for each clerkship-site.

Mean ratings for the different variables were computed by discipline and by hospital. In order to investigate the factors that students felt inhibited high-quality supervision, we identified two groups of clerkship-sites according to students’ global ratings on supervision: a group with relatively high ratings (>8.5 on a 10-point scale) and a group with relatively low ratings (<7 on a 10-point scale), henceforward referred to as the relatively high scoring and the relatively low scoring clerkship-sites. We included only the two groups of relatively extreme scoring clerkship-sites in this study because we expected them to provide better insights into factors inhibiting effective learning. There were nine relatively low scoring clerkship-sites, with a mean rating on supervision of 6.8 (SD=1.2, n=407; range 6.4-6.9): Paediatrics in hospitals A and B, Surgery in hospitals A and C, Gynaecology in hospitals A, B and D, and Ophthalmology in hospitals A and E, i.e. four disciplines in five hospitals. The number of student questionnaires available for each of these clerkship-sites varied between 13 and 143, with a total of 407. The relatively high scoring clerkship-sites had a mean rating of 8.7 (SD=0.9, n=131, range 8.6-9.2). They were: Paediatrics in hospitals C and E, Surgery in hospital F, Obstetrics/Gynaecology in hospital G, Ophthalmology in hospital B, ENT in hospital C, Neurology in hospital H and Dermatology in hospitals C, D and E, i.e. seven disciplines in seven hospitals. The number of student questionnaires available per high scoring clerkship-site varied between 7 and 25; in total 131. We calculated and compared the mean responses of the high and low scoring groups on the 10 end-of-clerkship questionnaire items. Ratings of less than 6 on the 10-point scale and less than 3 on the 5-point scale were regarded as unsatisfactory. Ratings of less than 7 on the 10-point scale and less than 3.5 on the 5-point scale were considered poor but not fully unsatisfactory, and a sign that improvement was needed.

In addition to the general and detailed ratings, we analysed open-ended comments regarding perceived weaknesses from students at clerkship-sites that scored relatively low on supervision. The first author read all negative comments and based on students’ comments, defined categories of responses. The second author also read the comments and the two authors discussed the adequacy of the response categories. The first and second authors then independently coded the comments. When they disagreed on coding, consensus was reached through discussion.


Students’ mean overall ratings on working climate, organisation, learning effectiveness and supervision were computed for the relatively low and relatively high scoring clerkships (Table 1). The greatest difference between group means (1.9) was found for supervision, which was expected since the two groups were selected on the basis of their divergent supervision ratings. The ratings on working climate, organisation, and learning effectiveness were lower for the low scoring clerkship-sites (6.8-7.4) than for the high scoring clerkship-sites (8.4 - 8.9). The fact that all scores were greater than 6 indicated that both high and low scoring clerkship-sites received satisfactory ratings even though the ratings on organisation and supervision were less than 7 for the low scoring clerkships, indicating a need for improvement in these realms.

Table 1:  Mean global ratings1 on global working climate, organisation, learning effectiveness and supervision at nine clerkship-sites with low and high ratings on global supervision.

Next, we compared the mean ratings (5-point scale) of the two groups on the five items about supervision (Table 2). The discrepancy between the groups was greatest for the items addressing time spent on supervision, the extent to which staff members explained what they were doing and why, and staff openness to giving explanations and answering questions. Regular observation during patient contacts received low ratings irrespective of a clerkship’s global ratings on supervision, with ratings of 2.2 and 3.0 for the low and high scoring clerkship groups, respectively.

Looking at absolute score values, only the item on students being observed by supervisors received an unsatisfactory rating at the low scoring clerkship-sites. Nevertheless, four of the five supervision item ratings were less than 3.5, which suggests a need for improvement.

Comparison of the mean scores on the five items about patient contacts (Table 2) found that the greatest group differences were the extent to which students were able to examine patients independently and the availability of facilities where students could examine patients. Groups also differed in the number of patients to which students were exposed. Although no item yielded a mean rating of less than 3.0, the low scoring clerkship-sites demonstrated ratings of less than 3.5 on the items addressing availability of exam space, the number of patients available to students, and student independence when interacting with patients, again suggesting a need for improvement.

Table 2:   Mean ratings1 on items addressing issues of supervision and patient contact for clerkship-sites with low and high ratings on global supervision.

Open-ended comments

More specific information about the factors inhibiting learning during clerkships was obtained from students’ comments on the perceived weaknesses of the low scoring clerkship-sites. Five categories of weaknesses were identified (Table 3); the two most common were too few opportunities to examine patients independently and receiving insufficient supervision and feedback. Comments in these categories were made by at least one student at each of the low scoring clerkship-sites. Examples of students’ comments are: “I received hardly any feedback, too little supervision”. Another category of comments were about staff not being motivated to teach and having negative attitudes towards students: “Some staff members ignored students” and “Staff members were not motivated to give explanations”. Students of some clerkship-sites noted that having too many students also inhibited learning: “There were too many students due to which you could examine fewer patients and practise fewer skills”. A last category of comments concerned poor organisation, for example “Staff did not know what they were expected to do with students” and “Contacts with too many different staff members”.

Table 3:  Categories of comments from students at clerkship-sites with low ratings on supervision about their weaknesses, with illustrative quotations.


By comparing evaluations from students at clerkship-sites scoring relatively low on supervision with evaluations from students at sites scoring relatively high and by analysing students’ comments regarding the perceived weaknesses of relatively low-scoring clerkships, we identified factors perceived to inhibit student learning in clinical settings. Our students perceived that clerkship-sites needed improvement in the time preceptors spent on supervision, the extent to which staff members explained what they were doing and why, providing more regular observation when students were interacting with patients, providing more opportunity for students to examine patients independently, and providing more adequate facilities for students to examine patients. Students’ open-ended comments indicated additional issues affecting learning, including a lack of motivation for teaching among staff and a negative attitude towards students, too many students competing for too few patients, and poor organisation of the students’ time and experiences. These comments also contained suggestions for improvement, among which were providing more opportunities for examining patients in the outpatient clinic and providing more continuity of supervision by assigning a single mentor for the duration of each clerkship. This latter suggestion is in line with findings from a previous study in which students in longitudinal clerkships noted the benefits of working with one teacher (Mihalynuk, 2008). Taken together, the findings of this study suggest that direct observation and feedback are too infrequent in our students’ clerkship sites, regardless of how overall supervision at the sites was rated. The inhibitory factors identified are likely interrelated. For example, when there are too many students, they likely are less able to examine enough patients and staff will have less time for supervising individual students.

Some students mentioned the staff’s lack of motivation towards teaching and negative attitudes such as ignoring students. It is interesting that in the fixed-response items students gave relatively high ratings to staff openness to giving explanations and answering questions, even in the clerkship-sites with relatively low supervision ratings. Perhaps student perceptions that staff lack motivation to teach are the exception rather than the rule. Regardless of how often it occurs, this perception requires remediation. That staff in some sites displayed negative attitudes towards students and teaching illustrates the bind of those working in clinical teaching sites created by their dual responsibilities to students and patients (Hofman & Donaldson, 2004; Deketelaere et al., 2006).

The fact that there were more respondents from low-rated clerkship sites might reflect that sites with more students had more problems handling their students and, consequently, were rated lower by students than clerkship-sites with fewer students. This would fit with comments from low-rated sites that there were too many competing students. Paradoxically, in an earlier study we found that the number of students did not significantly influence the effectiveness of clinical clerkships and that student learning was related more to the richness of the feedback than to student numbers (Dolmans et al., 2002b).

To the extent that these students were accurate in their assessments, what are the implications for educators? As others have found, we learn that to be effective clerkships should provide students with sufficient opportunities to examine patients with different clinical problems, both independently and with supervision. Irby and Bowen (2004) stress the importance of creating a positive learning environment, evaluating learners, providing feedback and promoting self-assessment, self-reflection and self-directed learning. The supervisory relationship, including the continuity of supervisors over time, is particularly important (Kilminster & Jolly, 2000). As one student observed: “[There were] contacts with too many different staff members”. Collins, Brown and Newman (1989), strong advocates of the cognitive apprenticeship model of student learning in situated learning environments, also emphasize the importance of modelling, coaching, observation and reflection for effective learning.


A shortcoming of this study is that the relatively lower ratings of some clerkship-sites did not actually reach levels indicating an unsatisfactory environment (6.8 on a scale from 1-10). Nevertheless, the data revealed factors that students perceived were inhibiting their learning. Another limitation of the study is that individual students completed questionnaires for four different clerkships, on average; therefore student responses are not fully independent. Furthermore, the response rates for students of two clerkships—surgery and ear, nose and throat—were rather low, 45% and 41% respectively. A further limitation is that the open-ended question asked students to indicate strengths and weaknesses of a clerkship-site and did not explicitly ask the students to indicate factors that might promote or inhibit student learning, which was the specific issue we were interested in and report on. A final limitation of this study is that it was based on students’ perceptions, which are sensitive to the expectations they bring to their clerkships. Future research should use direct observations of the supervision students actually receive during clerkships and assess the differences in the perceptions and needs for supervision between junior versus more senior students.


We would like to thank Diana Riksen for setting up the data-set. Thanks to Mereke Gorsira for revising the English.

Practice points

Too few opportunities to examine patients independently and insufficient time for supervision appear to inhibit student learning in the clinical learning environment.

Direct observation and feedback are too infrequent in the clinical learning environment both in clerkship-sites scoring relatively low and relatively high on supervision.

Assigning a personal mentor to a student during each clerkship might help promote continuity of supervision.

Ethics approval

This study was not submitted to an ethical approval committee within the University of Maastricht, the Netherlands, because no such committee is available nor is ethics review required in the Netherlands for educational research. Nevertheless, the student-participants of this study were protected by our gathering and analyzing data anonymously.


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Appendix 1:  Variables and corresponding items used for this study


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