Perspective

Conceptualizing Learning Environments in the

Health Professions
Larry D. Gruppen, PhD, David M. Irby, MDiv, PhD, Steven J. Durning, MD, PhD,
and Lauren A. Maggio, MS(LIS), PhD

Abstract
The learning environment (LE) is an the authors employed a living systems social, and organizational. Intertwined
important and frequently discussed perspective that draws on various with the psychosocial dimension at
topic in the health professions frameworks and theories, including each level is the material dimension,
education literature. However, there ecological psychology, workplace which encompasses physical and
is considerable inconsistency in how learning, situated cognition, and virtual spaces. This theoretical
the LE is defined and described. The sociomateriality theory. The conceptual lens can facilitate identifying and
authors propose a definition of the framework identifies five overlapping analyzing problems in the LE and
LE and a conceptual framework to and interactive core components that guide development of interventions to
facilitate health professions educators in form two dimensions: the psychosocial mitigate them. The authors conclude
understanding, studying, and designing dimension and material dimension. with several practical suggestions
interventions to improve the LE. To The psychosocial dimension comprises for health professions educators,
arrive at this conceptual framework, three components: the personal, investigators, and editors.

E ducators, researchers, and accreditors environment means “that which is more complete conceptual framework
have highlighted both the positive and around or surrounds”—the physical of the LE is required to make progress in
negative effects of learning environments or social world of a particular setting.6 understanding, studying, and designing
(LEs) on health professions education.1–3 So the “learning environment” literally interventions to improve it.
Learners thrive in settings where they means “that which surrounds learning.”
are welcomed, engaged, supported, and Another definition is “a set of features
challenged, but when learners perceive that gives each circumstance and Developing a Conceptual
the LE to be exclusionary, unsupportive, institution a personality, a spirit, a culture Framework for LEs
and/or abusive, this typically leads to and describes what it is like to be a A strong conceptual framework can
high levels of depression, burnout, learner within that organization.”7(p554) LE identify key elements of the LE, describe
marginalization, and/or exhaustion. The is a term that is often used synonymously how these elements influence learning,
impacts of LEs on learners within them with atmosphere, learning climate, and illustrate how they interact with each
have led to numerous efforts to measure organizational culture or milieu, and other. Notably, the construct of the LE
and improve such environments, yet educational environment. It describes is not “owned” by any particular theory
there is little uniformity in definitions the routine ways in which people interact or perspective. Indeed, all too often the
and measuring instruments.4,5 with each other and the tone of the LE is ignored in theories of learning,
social and cultural climate as well as the leaving this construct in something
The term “environment” comes from organizational structures and physical of a theoretical limbo. Until a robust
the Middle French word “environ,” spaces that surround learning.8 What conceptual framework of the LE is
which is translated as “around.” Thus, is consistent across research pertaining available, there will be limited progress in
to the LE is the observation that its assessing and improving the LE.
Please see the end of this article for information
purpose is to support the learning and
about the authors. development of all within that setting. There have been previous attempts to
frame the LE, according to a 2012 review
Correspondence should be addressed to Larry D.
Gruppen, Department of Learning Health Sciences, On the basis of a scoping review of the literature by Schönrock-Adema and
University of Michigan Medical School, 219 Victor conducted for a Josiah Macy Jr. colleagues.4 The first framework arose
Vaughan House, 1111 E. Catherine St., Ann Arbor, Foundation consensus conference on from the work of Murray10 in 1938. He
MI 48109-2054; telephone: (734) 936-1662;
email: [email protected]. improving environments for learning focused on describing the individual’s
in the health professions in April 2018,9 personality and how this influenced his
Written work prepared by employees of the Federal
Government as part of their official duties is, under we proposed the following definition: or her perceptions of the environment.
the U.S. Copyright Act, a "work of the United States “Learning environment refers to the The second framework was the work
Government" for which copyright protection under social interactions, organizational of Moos11,12 in the 1970s. Working in
Title 17 of the United States Code is not available. As
such, copyright does not extend to the contributions culture and structures, and physical and the context of higher education, Moos
of employees of the Federal Government. virtual spaces that surround and shape conceptualized each LE in terms of three
the learners’ experiences, perceptions, broad domains: personal development
Acad Med. 2019;94:969–974.
First published online March 12, 2019 and learning.” Even with a clear and or goal direction, which relates to
doi: 10.1097/ACM.0000000000002702 agreed-upon definition, we argue that a educational goals, constructive criticism

Academic Medicine, Vol. 94, No. 7 / July 2019 969

Perspective

and feedback, and relevant learning Within a situated learning perspective, the LE were poor quality of life leading
content; relationships, which focus learning involves acculturation into a to more emotional exhaustion, moral
on how learners and faculty members new knowledge community (becoming distress, depersonalization, and worries
support each other, demonstrate affiliation a member of a community) through about future endurance and capacity.
and emotional support, and have open active participation.14 Related theories, These factors reflect the psychological
communication; and system maintenance such as ecological psychology and characteristics of the learners, and their
and system change, which addresses such workplace learning, emphasize that experiences and perceptions of the
things as clear expectations, an open and social interactions related to learning environment.
orderly environment, innovation, and are facilitated by affordances in the
the extent of student influence. Moos’s environment with which learners actively For educators, the personal dimensions
framework has been used in many of the engage.15 Situated cognition and activity of their learners are of paramount
existing learner self-report measures of theory16 also emphasizes the social importance. Educators focus on learners’
the LE and accounts for over 90% of the character of learning and the interactions motivations, desire to develop progressive
items in those instruments.4 Building on of the learner with the environment. levels of autonomy, commitment to
Moos’s framework, Schönrock-Adema Specifically, knowledge is embedded in pursue larger goals and purposes, and
and colleagues4 argue for a three-domain the activity, context, and culture in which desire to work collaboratively with
framework of the LE for the health it is learned.17 Sociomateriality theory others. This personal, learner-centered
professions: goal orientation, relationships, builds on the intersection of technology, component of the LE strongly influences
and organization/regulation. work, and organizations—suggesting that learner experience, learning, and
the material dimensions and psychosocial perceptions. Indeed, most inventories
Genn’s5,13 2001 analysis of the LE dimensions of work are intertwined and designed to measure the LE are focused
highlights a major challenge to inseparable.18,19 on how individual learners perceive it,
developing a theory of the LE when but this imposes a limitation by focusing
he notes that almost anything can be on the individual while failing to address
Proposing a Conceptual
considered part of the LE if it has an the larger social, organizational, physical,
Framework for the LE
impact on learning. He illustrates this and virtual components of the LE.
complexity with a number of variables, Lacking a canonical theory of the LE, we
such as time tables, class composition, followed a living systems perspective20 (a Social component. The social
leisure time, clinical team members, general theory about all living systems, component of the LE characterizes
and many others. Such a comprehensive their structure, interaction, behavior, interactions and social relations with
framing raises the question of what isn’t and development) to synthesize multiple others, thus adding to the personal
part of the LE. A conceptual framework conceptual frameworks3,4,11–13,19,21,22 dimension. These relationships include
of the LE is valuable as much for what and identified five overlapping and peer-to-peer (competition, cooperation,
it would leave out as for what it would interactive core components that form shared values and learner culture),
include. two dimensions. The psychosocial learner-to-faculty/staff (trust, feedback,
dimension encompasses the LE at three clarity of expectations, communication,
We argue that the LE can be thought levels: the personal, the social, and instructional strategies, mentoring),
of as a complex psycho-social-physical the organizational. Cutting across this and learner-to-patient (responsibility,
construct that is cocreated by individuals, dimension is the material dimension, acceptance, trust) elements. The social
social groups, and organizations which includes physical and virtual component describes the quality of
in a particular setting and shaped spaces. These two dimensions interact these interactions, including equity and
by contextual climate and culture.8 to define multiple combinations of inclusion, and harassment and abuse of
Each of the frameworks described components that identify aspects of the learners. All of these social relationships
above emphasizes the importance of LE (Figure 1). influence what and how students
interactions and collaborations with learn and shape their perceptions
others “as the means for students’ Psychosocial dimension of and experiences with the LE. The
learning/participation, both through Personal component. The personal social component emerges through
learning knowledge and skills from component of the LE describes its these dynamic and often-interwoven
others, and through becoming familiar psychological dimension: how individual interactions. Interventions designed to
with the norms, cultural beliefs and learners interact with the LE, develop improve the social component include
attitudes existing in the communities perceptions of the LE, engage in personal faculty development workshops focusing
to which they (the learners) are being growth, and develop professional identity. on creating a positive learning climate,
introduced.”4(p739) However, the LE is From our scoping review,9 we identified peer coaching programs, diversity/
more than just social interactions. It interventions or factors positively equity/inclusion training, and teamwork
must also encompass intraindividual associated with the personal component training.9
psychological characteristics as well of the LE: time focused on direct patient
as physical spaces and virtual (digital) care, having a community of peers, a Investigations of the social component
environments. good quality of life and high levels of typically fall under the purview of
resilience, training in well-being, learning sociologists, anthropologists, and
We believe that a psychosocial in a “meaningful” practice, and trust in a ethnographers, who place high value on
perspective provides a solid foundation regulated system that supports learners. how individuals interact with each other
for building a conceptual framework. Factors with negative associations with and within a system. Emphasis on the

970 Academic Medicine, Vol. 94, No. 7 / July 2019

 Perspective

Figure 1 A conceptual model of learning environments.

social component is also evident in the premise of the CLER program is that in the midst of patient care. Availability
quality assurance literature. Theories the educational program and patient of an adequate number of examination
that pertain to this component include care will be improved if constructive rooms is essential for clinical learning,
situated learning, situated cognition, actions are taken regarding patient safety, given that students and residents typically
sociomateriality, and deliberate practice. health care quality, care transitions, take longer to examine patients than do
supervision, fatigue management, board-certified physicians. Interventions
Organizational component. Like and professionalism.23,24 We also designed to improve the LE associated
the social component of the LE, the include placements in the community with physical space include longitudinal
organizational component places (geographical settings/locations) in this and community placements.9 Space is
particular value on interactions and organizational component. also key to various educational resources,
the role of organizational culture and such as simulation facilities, anatomy
practice; unlike the social component, Deans, regulatory bodies, and labs, and computerized testing rooms.
the organizational component primarily policy makers typically focus on the The space component of the LE directs
addresses artifacts (or how people organizational component of the LE. attention to the quantity and quality
interact with objects or elements in Understanding the dynamics of how of spaces relevant to specific learning
their environment) and/or groups of the myriad organizational features activities.
individuals (who are not just a part of relate to the LE incorporates theories
the individual’s typical social circle). of sociocultural, sociomateriality, and Virtual spaces. In addition to
Thus, this component emphasizes physical space, the electronic learning
interpersonal interactions.
how individuals interact with policies, environments, curriculum management
navigate organizational performance Material dimension tools, and digital assistants that deliver
measures, and respond to culture and/or content to learners and provide forums
particular leadership actions. Physical spaces. The material dimension for interaction and learning are all part
of our LE framework includes the of the material dimension. However, the
Organizations provide structure, physical and virtual spaces in which material dimension also includes other
guidance, and/or support for learning. learning and practice occur as well as affordances in the environment (e.g.,
This support can take the form of objects (artifacts) in the environment just-in-time learning built into electronic
curriculum resources, geographic that affect learning (e.g., electronic health record systems, handheld devices,
placements, and accreditation rules, health record and order entry systems, computer networks).
as well as organizational practices, stethoscopes, laparoscopes). Physical
culture, and policies (such as duty space includes brick-and-mortar In alignment with sociomateriality
hours, regulatory environment, teacher campus-based teaching and learning theory, the material dimension is
control, curriculum). One example of buildings, hospitals and clinics, and “entangled in practice” with the
this is the Clinical Learning Environment community sites. Students search for psychosocial dimension such that the
Review (CLER) implemented by the conducive spaces for study, discussion, two dimensions inextricably interact.18,19
Accreditation Council for Graduate and team learning. Small conference For example, the electronic health record
Medical Education. The underlying rooms are critical to clinical education is a virtual LE, but this environment

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Perspective

is typically defined and experienced framework. The dependent variables interpretation of existing studies; its main
differently for the individual learner, the (DREEM questionnaire, interviews, purpose is prospective use in evaluating
medical team, and the institution overall. learner performance) all reflect the and improving the LE. For example, a
individual person component, while medical school might discover through
Despite the resources devoted to the size of student cohort and size of its routine surveillance of third-year
improving physical spaces and patient population reflect the social and student perceptions of their experiences
designing online courses, the study of organizational components. The material that there is a sudden increase in overall
the impact of the material dimension dimension of physical and virtual spaces student stress. As the school leaders seek
is underrepresented in the literature25 is not explicitly identified or described in to diagnose the cause and nature of this
and notably so in the study of the LE.9 the published findings, but it would not change, they could use our conceptual
This contrasts with studies undertaken be surprising to find LE differences due framework as a guide for exploring
in environmental psychology, business, to geographic location. An additional possible causes.
and higher education where the material area to investigate would be the support
dimension of the LE has led researchers resources needed for virtual learning, and Considering first the personal component
to strongly recommend studying the their impact. of the psychosocial dimension, the
integration of the psychosocial and administration might consider individual
material dimensions.18,26 Peer learning community and well- characteristics that are contributing to
being this sudden rise in stress. If the stress is
An international study examined the limited to a small number of learners,
Applying the Conceptual
relationship between favorable student there may be a shared attribute (e.g., first
Framework
perceptions of the LE and student generation in college, underrepresented
The value of any conceptual framework reports on quality of life, burnout, and in medicine, economic status, resilience).
lies in the guidance it provides for empathy.29 The study team employed If the stress was broadly distributed,
understanding problems and guiding cross-sectional surveys and relevant self- individual characteristics would seem less
the development of interventions to report instruments measuring burnout, likely.
solve those problems. We examine two quality of life, and empathy with medical
published studies through the lens of students in Israel, Ireland, China, and The social or interpersonal component of
our conceptual framework, then go on to Malaysia. Their findings indicated that the psychosocial dimension would be a
analyze a common problem in many LEs. positive LE perceptions were closely likely source of stress-inducing dynamics
associated with well-being and that or events. The social component is more
Community placements fostering peer community may enhance likely to be at work if the stress is widely
The Rural Clinical School of Western quality of life and reduce burnout. disseminated among learners. Social
Australia places first-year medical However, perceptions of the LE and causes to consider in this case might be a
students in longitudinal integrated empathy were not closely correlated. sudden increase in competition, conflicts
clerkships, in groups of 3 to 10 members, among segments of the class, unhealthy
in 10 different rural and remote sites.27 As in the previous example, the interactions between faculty and students,
Hoping to understand the influence of psychosocial component of our model or broadly shared perceptions of student
this LE, researchers developed a study encompasses the dependent variables (LE harassment and mistreatment. The
examining whether students at smaller perceptions, empathy, burnout, quality of sudden onset of stress would make some
sites were disadvantaged by the reduced life). The inclusion of multiple national of these potential causes more likely.
number of student colleagues and cultures, however, makes this study
by smaller patient populations. Data unusual in its inclusion of a component The organizational or institutional
included annual comparisons of end- on our psychosocial dimension (nation) component may also be a contributor.
of-year performance results, annual that is higher than the organizational Curriculum changes with required
midyear interviews, and the Dundee component. However, because there rotations away from home, strife between
Ready Education Environment Measure was only one institution studied in faculty and administration, mergers
(DREEM) survey.28 There were no each country, nation and organization and expansions of hospitals, or new
differences in results between smaller sites are confounded, and it is reasonable leadership are all institutional events that
and larger sites. Midyear interviews were to classify this study as comparing LEs can trickle down to affect student stress
shown to correlate significantly with the across differing organizations. The key if the environment takes on a threatening
findings from the DREEM questionnaire factor in this study, however, was the or uncertain tone.
in terms of student perceptions. Students existence of a community of peers within
at small sites were more satisfied with the organization, which clearly reflects On the material dimension, physical
their educational experience than those the social component of the psychosocial spaces may also contribute to the stress,
at the larger sites. End-of-year grades and dimension. Again, the material dimension if formally accessible spaces for study
learner satisfaction showed no differences of physical and virtual spaces was not and social interaction are taken offline
among site sizes. addressed in this study. or construction interferes with access
and capacity (e.g., library hours and
This study primarily illustrates both the Diagnosing a problem in the LE classroom access curtailed). Similarly,
personal and organizational components Our conceptual framework is by virtual infrastructure can trigger stress
of the psychosocial dimension of our no means limited to retrospective in the LE. For example, the adoption of

972 Academic Medicine, Vol. 94, No. 7 / July 2019

 Perspective

a new learning management system, or thinking about complex interactions Conference on Improving the Environment for
becoming familiar with a new electronic among the components of any given LE. Learning in the Health Professions, April 15–18,
2018, Atlanta, Georgia.
health record or electronic portfolio, can This framework could, for instance, also
all contribute to stress among learners. monitor disruptions to the LE such as the
L.D. Gruppen is professor, Department of Learning
devastation caused by Hurricane Katrina Health Sciences, University of Michigan Medical
This example also highlights the in 2005 to Louisiana State University School, Ann Arbor, Michigan; ORCID: http://orcid.
interaction between the work Health Sciences Center and Tulane org/0000-0002-2107-012.
environment and the LE. Health University.30,31 D.M. Irby is professor emeritus, Department of
professions education is tightly tied to Medicine, University of California, San Francisco, San
Francisco, California.
learning in practice, so the characteristics Our conceptual framework naturally
and dynamics of the workplace also leads to a number of recommendations. S.J. Durning is professor, Department of
become part of the LE. The influence of First, academic journals should not Medicine, and director, Graduate Programs in Health
Professions Education, Uniformed Services University
the work environment can be considered publish articles on the LE without the of the Health Sciences, Bethesda, Maryland.
within each of the components of our authors having defined the LE, describing
L.A. Maggio is associate professor, Department of
model. For the personal component, their conceptual framework and Medicine, and associate director, Graduate Programs
the work environment may accentuate specific LE(s) under discussion. Second, in Health Professions Education, Uniformed Services
stress created by individual anxiety researchers need to develop assessment University of the Health Sciences, Bethesda, Maryland;
methods that reflect the psychosocial and ORCID: http://orcid.org/0000-0002-2997-6133.
about performance, competence,
and the consequences of failure. The material dimensions to accurately assess
work environment also affects the the full dimensionality of LEs. Third, References
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