Clinical learning experience requires difficult adjustments for Across the United States, health care disparities persist, while the overall quality of health care continues to improve.1,2 These disparities occur across many dimensions, including but not limited to race and ethnicity, socioeconomic status, sexual orientation, and gender identity.1-3 For example, the National Academy of Medicine (formerly the Institute of Medicine) 2002 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care concluded that minority patients generally receive lower quality health care than whites in the United States, regardless of their insurance status or their ability to pay for care. In today’s language, one might say the teacher is still “the adult in the room”, in that he or she knows what needs to happen for learning to take place. Oxford University Press is a department of the University of Oxford. uality Clinical Learning Environment Each clinical nurse/midwife manager has a professional responsibility to ensure that the facilitating factors for providing a quality clinical learning environment are supported, to enable the student learn the practice of nursing/midwifery. The ... Clinical learning is a serious undertaking, since this is a testing ground where the student comes into contact with the reality of care, with all its attendant rituals and demands. Conclusion: Each of these skills are supported by a set of desired behaviors, which are outlined in Table 2. Exposing new clinicians to systems-based QI also provides them with the opportunity to see how well-informed, culturally appropriate QI projects have the potential to effect change and improve care across the organization. The findings also support the moderating role of clinical learning environment on the relationships between coaching supervision-talent development, mentoring supervision-talent development and abusive supervision-talent development among public hospital trainee doctors. What are health disparities and health equity? LEARNING ENVIRONMENT The Clinical Placement Provider is responsible for setting up a favourable learning environment; introduce best practices in clinical education to achieve students’ clinical learning outcomes. Health care disparities may be a result of (among other factors) the health care system itself (e.g., resources, incentives for keeping health care costs low); patient beliefs and behaviors (e.g., distrust of health care providers or refusal of treatment); and provider beliefs and behaviors (e.g., conscious and unconscious biases, prejudice, or uncertainty when it comes to treating certain patient populations).4 To address the complex nature of how these variables interact requires action at all levels of the health care system—from policy makers to health care organizations to individual members of the clinical care and administrative team. With this infrastructure in place, organizations can begin to engage new clinicians in QI focused on health care disparities, including the steps of (1) collecting and analyzing data to identify health care disparities and the CLE’s vulnerable patient populations; (2) using stratified data to develop focused, culturally appropriate QI efforts; (3) communicating QI findings to all relevant CLE staff, including new clinicians; (4) using QI findings to inform changes needed to eliminate health care disparities; and (5) conducting ongoing analyses to determine if changes resulted in the desired outcome and modifying the efforts as needed (see Table 2). USA.gov. The term learning environment can refer to an educational approach, cultural context, or physical setting in which teaching and learning occur. ment and active participation in clinical learning activi- ties” [7]. The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. Background/Aim. Chan School of Public Health, the Robert Wood Johnson Foundation, and National Public Radio showed that discrimination is an important barrier to equity in US health care.6 Of the 3453 people polled in the study, 32% of Black Americans, 23% of Native Americans, and 20% of Latinos reported experiencing discrimination when going to a doctor or health clinic, as did 18% of the women and 16% of the lesbian, gay, bisexual, transgender, and queer individuals participating in the survey.6. Driver diagram outlining the clinical learning environment’s role in supporting new clinical engagement in quality improvement to eliminate health care disparities. • Understands how the CLE continually identifies health disparities and health care disparities among its patient population. Clipboard, Search History, and several other advanced features are temporarily unavailable. Almost all of us have spent a great deal of time in the classroom, beginning in kindergarten and extending for years beyond. Purpose: The National Collaborative for Improving the Clinical Learning Environment offers guidance to health care leaders for engaging new clinicians in efforts to eliminate health care disparities. The National Academy of Medicine recommends that providers collect and stratify data on the access and use of health care by factors such as patients’ race, ethnicity, socioeconomic status, primary language, sexual orientation, and gender identity.4,14 Health care leaders can then use these stratified data to identify vulnerable populations at risk of or experiencing inadequate care or poorer health care outcomes.15 In addition to the categories noted above, health care organizations may also elect to collect or stratify data according to various subpopulations at risk—such as migrant populations or patients with disabilities—that help to further distinguish or identify disparities in care, especially in situations when the majority of the patient population is deemed vulnerable. The National Collaborative for Improving the Clinical Learning Environment Quality Improvement: Focus on Health Care Disparities Work Group, National Collaborative for Improving the Clinical Learning Environment, Chicago, IL. With new clinicians, CLEs have the opportunity to instill principles and imprint behaviors that potentially lay a foundation for how these clinicians will practice throughout their careers.3 By engaging clinicians in systems-level approaches to identifying and addressing health care disparities early in their clinical training, CLEs can foster a commitment to equity and continuous improvement that extends beyond their organization to wherever these individuals may practice in the future. [5,7] Nursing students have identified poor interpersonal relation-ships with clinical staff and preceptors as barriers to learn-ing within the clinical environment. Baretta R Casey, M.D., M.P.H., FAAFP, Baretta R Casey, M.D., M.P.H., FAAFP. Cultural humility is defined as a lifelong process of self-reflection that can inform one’s understanding of cultural differences and how such differences require sensitive approaches to health care.7,8 From a basis of cultural humility, health care organizations can begin to develop cultural competence—defined as “[a] set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.” 9 By focusing on culture, health care organizations can begin the work of ensuring that all patients have an equitable chance at attaining the best possible health outcomes (see box). Needless to say, when educators foster positive learning culture, learners are more likely to have the higher motivation that leads to better and more promising learning outcomes. For leaders of CLEs, a key part of this commitment is preparing and engaging their clinical workforce in efforts to eliminate disparities in health care. Summary: It is also where the The clinical learning environment is equivalent to a classroom for students during their practicums (Chan, 2004), yet few clinical agencies resemble traditional classrooms. [1 ,8 9] Negative experi-ences in the clinical setting often hindered learning and had Ecological psychology and workplace learning emphasize that social interaction is facilitated through affordances in the learning/working environment (tools, scaffolded relationships, tasks, language, concepts) and the active engagement of learners (through their agency, engagement and emerging autonomy) (Billett, 2001). Overall, the proposed model indicates a 26 % variance in talent development. BACKGROUND: Clinical facilities are essential components not only of health care delivery systems, but also of health care education programs. If so, you were lucky to have a teacher who paid close attention to the learning environment, or the For hospitals, medical centers, and clinical care providers, a key part of ensuring health equity is to have a systematic approach to identifying and eliminating health care disparities related to the care provided by their organization. To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Differences between groups in health insurance coverage, access to and use of care, and quality of care received. Equipped with this information, organizations can develop and implement focused, culturally responsive QI efforts to address the identified disparities.16. At all levels of the CLE, leaders play a central role in developing and sustaining the foundational elements noted above and ensuring they remain a priority throughout the organization. The clinical environment consists of inpatient, hospital outpatient and community settings, each with their own distinct challenges. Clinical learning environments involve three key elements: clinical work; learning; and environment. With foundational elements in place, CLEs are better positioned to prepare new clinicians with the skills and desired behaviors needed to effectively engage in systems-based QI to identify and eliminate health care disparities. By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers-and helping pave the road towards equity throughout the US health care system. Baretta R Casey, M.D., M.P.H., FAAFP, Marie Chisholm-Burns, Pharm.D., M.P.H., M.B.A., FCCP, FASHP, FAST, Morgan Passiment, M.S, Robin Wagner, M.H.S.A., RN, Laura Riordan, M.S, Kevin B Weiss, M.D, Role of the clinical learning environment in preparing new clinicians to engage in quality improvement efforts to eliminate health care disparities, American Journal of Health-System Pharmacy, Volume 77, Issue 1, 1 January 2020, Pages 39–46, https://doi.org/10.1093/ajhp/zxz251. The Nursing and Midwifery Council (2008) has defined mentors a… Hafferty described three components of the educational milieu: (1) the stated, intended, and formally offered and endorsed curriculum; (2) an unscripted, predominantly ad hoc and highly inter-personal form of teaching and learning that takes place among or between faculty and students (the informal curriculum); and (3) a set of influences that function at the level or organizational structure and …  |  Learners are motivated by its relevance and through active participation. NCICLE takes the view that actions to eliminate health care disparities that result from discrimination in care begin with establishing a culture of equity. The NCICLE work group identified the following elements as key to providing a solid foundation for engaging new clinicians in efforts to identify and eliminate health care disparities: CLEs with a culture of equity prepare their entire workforce (including new clinicians) to practice cultural humility and to engage in a continuous process of reflection, learning, and improvement that promotes culturally sensitive care. By preparing and supporting new clinicians to engage in systems-based QI efforts to eliminate health care disparities, clinical learning environments are instilling skills and supporting behaviors that clinicians can build throughout their careers—and helping pave the road towards equity throughout the US health care system. • Develop a clear strategy for eliminating health care disparities occurring within the organization that includes investment in infrastructure and resources at all levels of the organization to prioritize and support initial efforts and to sustain successful ones. Summary: To address health care disparities that are pervasive across the United States, individuals at all levels of the health care system need to commit to ensuring equity in care. Disparities. Abbreviations: CLE, clinical learning environment; QI, quality improvement. Early and frequent clinical experiences should be planned and integrated in curricula. A supportive clinical learning environment (CLE) is vital to the success of the teaching learning process. With better understanding of attributes comprising the clinical learning environment, nursing education programmes and healthcare agencies can collaborate to create meaningful clinical experiences and enhance student preparation for the professional nurse role. Get the latest public health information from CDC: https://www.coronavirus.gov, Get the latest research information from NIH: https://www.nih.gov/coronavirus, Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. NIH Participate in Analysis of Health Care Disparities. An important component of this culture is the expectation of cultural humility. Learners want to feel welcome and accepted by staff and they want staff to help teach them how to practice confidently and competently (Courtney-Pratt, FitzGerald, Ford, Marsden & Marlow… Learning in the clinical environment has many strengths. Accreditation Council for Graduate Medical Education. National efforts have substantially raised the visibility of health care disparities in the United States.1,2,4,9 Regardless of this visibility, disparities in care continue to persist throughout the US health care system, leading to poorer health outcomes for vulnerable patient populations. • Work closely with the QI leadership to design and implement programs for optimal clinical learning across professions in the area of QI focused on eliminating health care disparities. Clinical learning environments, or the hospitals, medical centers, and ambulatory care clinics where new clinicians train, have an important role in this process. Hospitals, ambulatory care sites, and other CLEs in which new clinicians train have an important role in preparing and supporting the clinical workforce to provide high-quality care for vulnerable populations. The Journal of Continuing Education in Nursing | Hospitals, clinics, and community agencies serve as clinical learning environments (CLEs) for … It is the responsibility of higher education institutes (HEI) in partnership with the NHS to prepare nurses and midwives to cope with the complex nature of clinical practice (Burns and Paterson, 2005). To better understand and ultimately eliminate health care disparities, our nation’s health care organizations will need to systematically assess and address the inequities affecting their patient populations. US Office of Disease Prevention and Health Promotion website. Faculty and others within the clinical learning environment who participate in training new clinicians. Robust, systems-based and systems-wide approaches to QI are key to health care organizations’ success in addressing health care disparities. Clinical teachers have an extremely important role in the effectiveness of clinical education in supporting learners, encouraging reflection, and providing constructive and regular feedback. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.” 10. • Participates in CLE processes to continuously monitor its efforts to identify and eliminate health care disparities. These tools also serve as useful guides for monitoring and assessing progress toward the aims.19Figure 1 provides an example of how CLEs might organize the guidance offered in this document into a set of aims, primary drivers, and secondary drivers. A lifelong process of self-reflection and self-critique that can inform one’s understanding of cultural differences and how such differences require sensitive approaches to health care.7,8. Because respiratory therapy (RT) is a practice-based profession, it is essential to integrate clinical education into RT education. Thank you for submitting a comment on this article. This is an open-access article distributed under the Creative Commons Attribution-Noncommercial-Share Alike 4.0 International License. Search for other works by this author on: Marie Chisholm-Burns, Pharm.D., M.P.H., M.B.A., FCCP, FASHP, FAST, College of Pharmacy and College of Medicine, University of Tennessee Health Science Center, Clinical Learning Environment Review Program, Accreditation Council for Graduate Medical Education, Address correspondence to Ms. Passiment (, Agency for Healthcare Research and Quality, 2016 National Healthcare Quality and Disparities Report, Lesbian, gay, bisexual, and transgender health, US Office of Disease Prevention and Health Promotion website, The effects of training institution practice costs, quality, and other characteristics on future practice, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, Implicit bias in healthcare professionals: a systematic review, Cultural humility is the first step to becoming global care providers, Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. 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