Japanese dental trainees’ perceptions of educational environment in postgraduate training

Abstract

Background: Compulsory postgraduate dental training was introduced in April 2006 to meet social requirements in Japan.

Aim: The aim of the present study was to identify the difference in trainees’ perception of the educational environment in two different training settings in the Hiroshima University Hospital postgraduate training program: (1) main hospitals, in Hiroshima's case, the University Hospital: (2) community dental hospitals or offices (cooperating hospitals).

Methods: In order to determine how trainees perceive their educational environment, the Postgraduate Hospital Educational Environment Measure (PHEEM) Inventory was administered to 50 vocational dental trainees for two different training settings, both of which all trainees had experienced.

Result: The mean total PHEEM score in the main hospital was 102.4, and that in cooperating hospitals was 108.5. The scores for each of the three subscales were as follows: ‘Perception of role autonomy’: 33.9/56 (main hospital), 36.8/56 (cooperating hospitals); ‘Perception of teaching’: 38.1/60 (main hospital), 41,9/60 (cooperating hospitals), and ‘Perception of social support’: 30.4/44 (main hospital), 29.8/44 (cooperating hospitals) respectively.

Conclusions: PHEEM provided meaningful diagnostic information on the educational environment, and showed that cooperating hospitals met trainees’ needs more than main hospitals.

Introduction

Japanese dental education has undergone extensive change over the last decade to meet the expansion of public interest in medical issues (Onishi & Yoshida 2004). Most of this educational change has been intrinsic, requiring a new awareness of health education within the faculty. One topical issue was the one-year compulsory postgraduate dental training program that started in April 2006, followed by postgraduate medical training. The aim of this training is to supplement the lack of clinical training in the undergraduate curriculum and to meet social requirements. In general, the majority of Japanese graduates from dental school do community dental health service as general dental practitioners in their own clinic and all graduates who wish to do it in their future career have to participate in this one-year program. So this training program has strong force for them. However they can select their training program through the Japan Residency Matching Program (JRMP), which helps to maintain a balance between trainees and educational institutes. Each training program involves a group of educational settings e.g., a main hospital (usually university hospital or community key hospital), and cooperating hospitals (for example, a private dental clinic). The trainee, after choosing one training program, has to decide on training hospitals within the program.

Table

Practice points
The perception of educational environment could reflect trainees’ satisfaction for learning. Measuring the educational environment provides appropriate feedback to improve training program. PHEEM is easy to use and easy to understand for all involved in postgraduate training.

On the other hand, the provider of education has to control the educational environment to ensure the quality of their training. A university hospital, as an educational institute and a community dental office, cannot offer the same content of education because the objective of their establishment is totally different. This training program aims at offering various types of education based on the original trait of each institute, and it is thus necessary to monitor whether the education offered matches the trainees’ needs or not.

Some attempts to investigate learners’ perceptions of their learning environment in dental education have been conducted; however, researchers hitherto have not used a well-defined inventory format (Henzi et al. 2005, 2006; Stewart et al. 2006). Furthermore, only a few tools are available specifically to assess the quality of the clinical learning environment. This study examined dental trainees’ perception of the Hiroshima University Hospital postgraduate dental training program using a 40-item Postgraduate Hospital Educational Environment Measure (PHEEM) Inventory developed by Roff et al. (2005). This instrument has been validated (Aspegren et al. 2007) and been shown to be reliable (Boor et al. 2007; Clapham et al. 2007).

The aim of this study was to identify the difference of trainees’ perception of educational environment in different training settings and to obtain information to contribute to the improvement of the Hiroshima University Hospital postgraduate dental training program.

Methods

Subjects

50 vocational dental trainees (30 male and 20 female, average 26.9 years old), who had just graduated from dental school attended the Hiroshima University Hospital postgraduate dental training program. All of them participated in this study.

Setting

The one-year Hiroshima University Hospital postgraduate dental training program was implemented in two educational settings. One was Hiroshima University Hospital (main hospital), which offered specific education by expert teachers or senior doctors and also had responsibility to manage the overall program and individual progress. The other was a group of community dental hospitals or clinics (cooperating hospitals), which supplemented the training of the main hospital in areas such as community dental health service, social health promotion etc. (outreach training). All trainees in this program experienced these two educational settings and the average duration of outreach training was 5.4 months per trainee.

Assessment of educational environment

Before using PHEEM as an assessment tool of educational environment, it was translated into Japanese. To ensure its authenticity a professional translator and an expert in medical education were involved. PHEEM consists of 40 items to which the respondents were asked to indicate their agreement using a five-point Likert scale with 4 = strongly agree, 3 = agree, 2 = unsure, 1 = disagree and 0 = strongly disagree. Four items are negatively described and scored in reverse (Table 1). The possible maximum score is 160 and the minimum score is 0. All items are grouped by three subscales: 1, perception of role autonomy; 2, perception of teaching; and 3, perception of social support.

Table 1.  Scores for each item in the Hiroshima University Hospital postgraduate training program (n = 50)

		Main hospital		Cooperative hospitals
Item number	Statement	Mean	SD	Mean	SD
1	I have a contract of employment that provides information about hours of work	3.2	0.65	3.2	0.68
2	My clinical teachers set clear expectations	2.7	0.88	2.8	1.09
3	I have protected educational time in this post	2.9	0.73	2.8	0.92
4	I had an informative induction programme	2.5	0.77	2.7	0.95
5	I have the appropriate level of responsibility in this post	2.6	0.84	2.8	1.03
6	I have good clinical supervision at all times	2.5	0.97	2.9	1.11
7	There is racism in this post	2.8	1.17	2.6	1.44
8	I have to perform inappropriate tasks	1.8	1.06	1.7	1.21
9	There is an informative Junior Doctors handbook	1.9	0.94	1.6	1.14
10	My clinical teachers have good communication skills	2.7	0.79	3.1	1.08
11	I am bleeped inappropriately	2.7	1.11	3.0	1.21
12	I am able to participate actively in educational event	2.6	0.84	2.7	1.07
13	There is sex discrimination in this post	3.1	1.03	3.0	1.26
14	There are clear clinical protocols in this post	1.9	0.96	1.6	1.26
15	My clinical teachers are enthusiastic	2.6	1.01	3.0	1.16
16	I have good collaboration with other doctors in my grade	2.9	0.61	2.9	1.10
17	My hours conform to the New Deal	2.9	0.54	3.0	0.90
18	I have the opportunity to provide continuity of care	2.6	0.86	2.7	1.24
19	I have suitable access to careers advice	2.4	0.79	2.6	1.18
20	This hospital has good quality accommodation for junior doctors, especially when on call	2.5	0.91	2.3	1.14
21	There is access to an educational programme relevant to my needs	2.2	0.92	2.1	1.06
22	I get regular feedback from seniors	2.4	1.01	2.9	1.12
23	My clinical teachers are well organised	2.0	1.07	2.6	1.16
24	I feel physically safe within the hospital environment	2.9	0.73	2.7	1.07
25	There is a no-blame culture in this post	2.5	0.84	2.5	1.25
26	There are adequate catering facilities when I am on call	3.0	0.82	2.6	1.05
27	I have enough clinical learning opportunities for my needs	2.6	0.81	2.8	0.97
28	My clinical teachers have good teaching skills	2.6	0.75	3.0	1.07
29	I feel part of a team working here	2.6	0.84	2.9	1.10
30	I have opportunities to acquire the appropriate practical procedures for my grade	2.3	0.99	2.9	1.07
31	My clinical teachers are accessible	2.7	0.79	2.9	0.96
32	My workload in this job is fine	2.0	0.97	3.0	0.90
33	Senior staff utilises learning opportunities effectively	2.5	0.79	2.6	1.15
34	The training in this post makes me feel ready to be a SpR/Consultant	2.4	1.08	2.9	1.19
35	My clinical teachers have good mentoring skills	2.6	0.75	3.0	1.07
36	I get a lot of enjoyment out of my present job	3.0	0.71	2.9	1.14
37	My clinical teachers encourage me to be an independent learner	2.7	0.76	3.0	1.09
38	There are good counselling opportunities for junior doctors who fail to complete their training satisfactorily	2.6	0.93	2.7	1.08
39	The clinical teachers provide me with good feedback on my strengths and weaknesses	2.5	0.74	2.8	1.00
40	My Clinical teachers promote an atmosphere of mutual respect	2.5	0.79	2.8	1.11
Mean total scores		102.4	19.99	108.5	30.12

Notes: Items in italics has been reverse coded. Paired t-test was used to compare the data between mean total scores.

All fifty trainees were required to answer the same PHEEM inventory for both training settings at the end of the training program (the end of March 2007).

Statistical analysis

To analyse the difference in dental trainees’ responses between two training settings, the main and cooperating hospitals, Wilcoxon signed-rank test was used. Paired t-test was also used to make comparisons of mean total scores of all items, and within each subscale (Stat View Ver.5.0).

Results

All 50 trainees answered all 40 items of PHEEM for each setting (response rate was 100%). Table 1 showed the mean item scores and standard deviations in the two training settings. The mean total PHEEM score in main hospital was 102.4, and in the cooperating hospitals was 108.5, and no significant difference was observed between them. The scores for each of the three subscales were as follows: (1) perception of role autonomy 33.9/56 (main hospital), 36.8/56 (cooperating hospitals) (Table 2); (2) perception of teaching 38.1/60 (main hospital), 41,9/60 (cooperating hospitals) (Table 3); (3) perception of social support 30.4/44 (main hospital), 29.8/44 (cooperating hospitals) (Table 4).

Table 2.  Subscale 1: Perceptions of role autonomy

		Main hospital		Cooperative hospitals
Item number	Statement	Mean	SD	Mean	SD
1	I have a contract of employment that provides information about hours of work	3.2	0.65	3.2	0.68
4	I had an informative induction programme	2.5	0.77	2.7	0.95
5	I have the appropriate level of responsibility in this post	2.6	0.84	2.8	1.03
8	I have to perform inappropriate tasks	1.8	1.06	1.7	1.21
9	There is an informative Junior Doctors handbook	1.9	0.94*	1.6	1.14
11	I am bleeped inappropriately	2.7	1.11	3.0	1.21
14	There are clear clinical protocols in this post	1.9	0.96	1.6	1.26
17	My hours conform to the New Deal	2.9	0.54	3.0	0.90
18	I have the opportunity to provide continuity of care	2.6	0.86	2.7	1.24
29	I feel part of a team working here	2.6	0.84*	2.9	1.10
30	I have opportunities to acquire the appropriate practical procedures for my grade	2.3	0.99**	2.9	1.07
32	My workload in this job is fine	2.0	0.97**	3.0	0.90
34	The training in this post makes me feel ready to be a SpR/Consultant	2.4	1.08**	2.9	1.19
40	My clinical teachers promote an atmosphere of mutual respect	2.5	0.79	2.8	1.11
Mean total scores		33.9	6.96**	36.8	9.20

Notes: Wilcoxon signed-rank test was used to compare the data of each item. *p < 0.05, **p < 0.01. Paired t-test was used to compare the data between mean total scores. **p < 0.01.

Table 3.  Subscale 2: Perceptions of teaching

		Main hospital		Cooperative hospitals
Item number	Statement	Mean	SD	Mean	SD
2	My clinical teachers set clear expectations	2.7	0.88	2.8	1.09
3	I have protected educational time in this post	2.9	0.73	2.8	0.92
6	I have good clinical supervision at all times	2.5	0.97	2.9	1.11
10	My clinical teachers have good communication skills	2.7	0.79*	3.1	1.08
12	I am able to participate actively in educational events	2.6	0.84	2.7	1.07
15	My clinical teachers are enthusiastic	2.6	1.01	3.0	1.16
21	There is access to an educational programme relevant to my needs	2.2	0.92	2.1	1.06
22	I get regular feedback from seniors	2.4	1.01**	2.9	1.12
23	My clinical teachers are well organised	2.0	1.07**	2.6	1.16
27	I have enough clinical learning opportunities for my needs	2.6	0.81	2.8	0.97
28	My clinical teachers have good teaching skills	2.6	0.75	3.0	1.07
31	My clinical teachers are accessible	2.7	0.79	2.9	0.96
33	Senior staff utilises learning opportunities effectively	2.5	0.79	2.6	1.15
37	My clinical teachers encourage me to be an independent learner	2.7	0.76	3.0	1.09
39	The clinical teachers provide me with good feedback on my strengths and weaknesses	2.5	0.74*	2.8	1.00
Mean total scores		38.1	8.91*	41.9	12.91

Notes: Wilcoxon signed-rank test was used to compare the data of each item. *p < 0.05, **p < 0.01. Paired t-test was used to compare the data between mean total scores. *p < 0.05.

Table 4.  Subscale 3: Perceptions of social support

		Main hospital		Cooperative hospitals
Item Number	Statement	Mean	SD	Mean	SD
7	There is racism in this post	2.8	1.17	2.6	1.44
13	There is sex discrimination in this post	3.1	1.03	3.0	1.26
16	I have good collaboration with other doctors in my grade	2.9	0.61	2.9	1.10
19	I have suitable access to careers advice	2.4	0.79	2.6	1.18
20	This hospital has good quality accommodation for junior doctors, especially when on call	2.5	0.91	2.3	1.14
24	I feel physically safe within the hospital environment	2.9	0.73	2.7	1.07
25	There is a no-blame culture in this post	2.5	0.84	2.5	1.25
26	There are adequate catering facilities when I am on call	3.0	0.82*	2.6	1.05
35	My clinical teachers have good mentoring skills	2.6	0.75*	3.0	1.07
36	I get a lot of enjoyment out of my present job	3.0	0.71	2.9	1.14
38	There are good counselling opportunities for junior doctors who fail to complete their training satisfactorily	2.6	0.93	2.7	1.08
Mean total scores		30.4	5.65	29.8	9.11

Notes: Wilcoxon signed-rank test was used to compare the data of each item. *p < 0.05. Paired t-test was used to compare the data between mean total scores.

Several statistically significant differences in each item were found between the two training settings. In subscale 1, the score of the main hospital was significantly higher than that of cooperating hospitals in item number 9, however in items 29, 30, 32 and 34 the score of cooperating hospitals was significantly higher than the main hospital. In subscale 2, the score of cooperating hospitals was significantly higher than that of main hospital in items 22, 23 and 39. In subscale 3, the score of main hospital was significantly higher than that of cooperating hospitals in item number 26.

Discussion

A revised postgraduate training system, compulsory for all graduates of dental school who wish to serve community dental health service in their future career, was introduced nationwide in 2006. Many kinds of reform were required in the Hiroshima University Hospital postgraduate dental training program to meet the needs of dental trainees. We used the PHEEM inventory as the only instrument to assess educational climate of hospital-based postgraduate training. Before introducing it for the 2006 training program, we tried it for the 2005 training program which was not obligatory for graduates and many kinds of problem appeared, such as defects of training support structure including lack of specific facilities (Taguchi et al. 2007). To prepare the new phase of postgraduate training, we improved program context and managerial structures.

In this study, the high response rates showed the trainees’ interest in educational climate as an appropriate opportunity to express their opinions. The difference between two training settings in the mean total score was somewhat to be expected. The high total score in cooperative hospitals indicates a more appropriate educational environment than the university hospital, however according to the interpreting guide of overall score (Table 5), each setting was classified into ‘more positive than negative but room for improvement’. Ohmaru et al. (2007) examined the educational environment of Kyushu University Hospital postgraduate dental training program, which runs under the same law providing Japanese postgraduate dental training, in 2005 by means of PHEEM. Their data was not calculated in individual training settings, but their mean total score was 107.7, which was the mean value of our data between main and cooperating hospitals.

Table 5.  Interpreting the subscale

Overall score of PHEEM
0–40	Very poor
41–80	Plenty of problem
81–120	More positive than negative but room for improvement
121–160	Excellent
Subscale 1 perception of role autonomy
0–14	Very poor
15–28	A negative view of one's role
29–42	A more positive perception of one's job
43–56	Excellent perception of one's job
Subscale 2 perception of role teaching
0–15	Very poor quality
16–30	In need of some retraining
31–45	Moving in the right direction
46–60	Model teachers
Subscale 3 perception of role social support
0–11	Very poor quality
12–22	In need of some retraining
23–33	Moving in the right direction
34–44	Model teachers

Table 5 shows the criteria in each subscale. The mean total score of main hospital and cooperating hospitals in subscale 1 were classified into ‘a more positive perception of one's job’. The score of cooperating hospitals was significantly higher than that of the main hospital (p < 0.01). This data suggests trainees recognized their responsibility for their learning in cooperating hospitals rather than in the main hospital, perhaps because cooperative hospitals offered a concrete image of their future career. For example, items 30, 32, 34 whose scores were significantly higher in cooperating hospitals than that of main hospital, indicated trainees’ sense of fulfillment and satisfaction with their learning.

The mean total score of main hospital and cooperating hospitals in subscale 2 was classified into ‘moving in the right direction’. The score of cooperating hospitals was significantly higher than that of main hospital (p < 0.05). This score could be influenced by their perception of their trainer, and may suggest it was easier to establish an appropriate relationship between trainee and trainer in cooperating hospitals than in the main hospital. Items number 22, 23 and 39, where scores of cooperating hospitals were significantly higher than that of main hospital, also relate to these relationships between trainees and trainers.

Mean total score of main hospital and cooperating hospitals in subscale 3 were classified into ‘more pros than cons’. The score of cooperating hospitals was lower than that of the main hospital, but no significant difference was observed between them. Lack of social support structure is a weak point of cooperating hospitals. One of the reasons is that these hospitals were not originally established as educational institutes, so they had no experience in teaching trainees in the workplace and inadequate facilities to create an appropriate training environment. On the other hand, the university hospital had long experience of clinical training and basic social support structures such as career advice centres and counselling services.

Roff et al. (2005) suggests PHEEM can be used to pinpoint more specific strengths and weaknesses within the educational climate. To do this, items that have a mean score of 3.5 or over are real positive points, any item with a mean of 2 or less should be examined more closely as they indicate problem areas, items with a mean between 2 and 3 are aspects of the climate that could be improved. According to these criteria, the lower average scores (items 8, 9 and 14), which were assessed as problem areas, were all categorized into the subscale ‘perception of autonomy’. Item number 8, ‘I have to perform inappropriate tasks’, shows how the trainee feels about the task in the clinical training. The low average scores in item number 9, ‘there is an informative Junior Doctors Handbook’, shows a difficulty in understanding the handbook, or a complete lack of written guidance. In the main hospital this reflects the complexity of business to be done at Japanese University Hospitals, and in cooperative hospitals it reflects the fact that they are not educational institutes but health service providers, often with no appropriate manual or protocol for junior doctors. The results in number 14 would be due to the same background conditions.

These scores of individual PHEEM items provide a clear indication from the learner's perspective of where the areas to be improved lie. We hope this contributes to the improvement of future training programs. Educational environment is a measure of one sector of 360 degrees assessment, one of the key issues in recent health care education. Training program evaluation from a broader perspective will enable it to be even more reliable and valid.

Conclusion

PHEEM provided meaningful diagnostic information on the educational environment and it enables us to compare different settings of clinical training. It has made it clear that there were differences in trainees’ perception between the main hospital and cooperating hospitals. From the result, it appears that the overall educational environment of cooperating hospitals came closer to meeting trainees’ needs, but further study is needed to confirm this. It is necessary to ascertain the trainees’ individual needs and characteristics of the educational program, and encourage self-directed learning. The results obtained in this study are considered appropriate feedback from learners and are serving as a baseline for strategic improvement of the training program.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Norihiro Taguchi

NORIHIRO TAGUCHI D.D.S., Ph.D. is assistant professor of general dentistry at Hiroshima University Hospital, Japan. He is engaged as program coordinator within the postgraduate dental training program of Hiroshima University Hospital.

Tetsuji Ogawa

TETSUJI OGAWA D.D.S., Ph.D. is professor of general dentistry at Hiroshima University Hospital, Japan. He also serves as vice president of Hiroshima University Hospital and director within postgraduate dental training program of Hiroshima University Hospital.

Hisako Sasahara

HISAKO SASAHARA D.D.S., Ph.D is researcher of preventive dentistry at Hiroshima University Hospital, Japan. Her research interests include statistical analysis and postgraduate dental education.