Aalam et et al, 2018 23
|
USA and Saudi Arabia |
Cross-sectional |
Emergency medicine residents. |
Adapted PHEEM |
3 emergency medicine programs in Saudi Arabia and 3 emergency medicine programs in the USA. |
Compare the educational environment between the USA and Saudi Arabian programs. |
219 |
USA: 118.7 SA: 109.9 |
A: 41.8(USA)X 38.1 (SA) |
USA: feeling like part of the team, clear training instructions, protected study time SA: protected time for study, good collaboration with other doctors, feeling part of the team. |
USA: food during shifts, accommodation during shifts, opportunity to continue monitoring the patient. SA: food during shifts, opportunity to continue monitoring the patient, culture of blaming the resident. |
US programs score higher overall. Mean scores differ on the autonomy and teaching scales, but not on the social support scale. US programs have more resources like simulation rooms and access to conferences and lectures. |
T: 46.5(USA) X 43.1 (SA) |
S: 30.5(USA) X 28.6 (SA) |
Ahmad et al , 202124
|
Pakistan |
Cross-sectional |
Residents of several specialties |
Adapted PHEEM |
4 tertiary hospitals in Pakistan: 3 public and 1 private |
To assess the educational environment in medical residency teaching hospitals in Pakistan. |
195 |
Public Hospitals: 72.6(17.6) |
A:23.6 (16.2) |
Feeling safe in the work environment, good collaboration with the work team. |
Sexual discrimination, culture of blaming the resident, lack of time to study. |
In private hospitals, the educational environment was considered worse than in public hospitals. It is necessary to improve the educational environment and, especially, eradicate sexual discrimination. |
Private Hospitals: 61.31(25.03) |
T: 24.1(16.9) |
S:19.3(13.2) |
Akdeniz et al , 201525
|
Turkey |
Cross-sectional |
Family Medicine Residents |
PHEEM, MBI |
Department of Family Medicine of Universities: 21 Hospitals of the Ministry of Health: 11 |
To evaluate the educational environment and burnout in Family Medicine programs. |
174 |
66.0(30.5) |
A:26.4(9.4) |
Not reported. |
Not reported. |
Perception of autonomy, teaching and social support below average, indicating a need for improvement. Levels of personal satisfaction, depersonalization and emotional exhaustion were within the range considered normal. |
T:25.7(10.9) |
S:18.7(7.6) |
Aspergren et al, 200726
|
Denmark |
Cross-sectional |
Residents of several specialties (internal medicine, neurology, oncology, pediatrics, surgery, orthopedics, gynecology and obstetrics, and radiology). |
Adapted PHEEM |
Residents from several departments and specialties. |
Translate into Danish and validate PHEEM in the country. A reduced version of PHEEM was used. |
342 (159 seniors and 183 juniors) |
Not reported. |
Not reported. Evaluated the average for each PHEEM item. |
Information about the program, appropriate level of responsibilities, feeling part of the work team. |
Being called at inappropriate times, lack of information about working hours, food during shifts. |
The questionnaire has been validated for use in Denmark. |
Bari et al, 201827
|
Pakistan |
Cross-sectional |
Residents in pediatrics, pediatric surgery and pediatric diagnosis |
PHEEM |
Lahore Children’s Hospital, Pakistan |
To evaluate the residents’ perception of the educational environment and compare perceptions between different specialties and years of residency. |
160 |
88.16 (14.18) |
A:29.27 (7.09) |
Adequate level of responsibility, good opportunities to perform hands-on procedures and good collaboration with other doctors. |
Food during shifts, inadequate working hours, lack of a working hours contract, lack of an informative manual for residents. |
There was no significant difference between specialties and different years of residency. The social support subscale showed a more negative perception as an unpleasant environment. |
T: 34.35 (9.66) |
S:21.58 (6.59) |
Berrani et al, 2020 28
|
Morocco |
Cross-sectional |
Residents of different specialties: internal medicine, surgery, pediatrics, anesthesiology, intensive care, gynecology and obstetrics and laboratory medicine |
Adapted PHEEM |
Six hospitals in Rabat (capital of Morocco) |
To evaluate the educational environment of residents in Morocco and compare the perceptions of residents of different specialties. |
255 |
81.4 (21.8) |
A:31.9 (8.3) |
Preceptors with good teaching skills, accessible preceptors, faculty encourage resident autonomy. |
Accommodation during shifts, food during shifts, not feeling safe in the hospital, sexual discrimination (reported by half of residents) and racial discrimination, culture of blame. |
Valid and reliable instrument. Residents in laboratory medicine had higher PHEEM values than those in other specialties, especially those in surgery and gynecology and obstetrics. The main problems are poor infrastructure, inadequate quality of supervision and teaching, and inadequate work regulations. |
T:33.2 (10.1) |
S:18.2 (21.8) |
Bigotte Vieira et al, 2016 29
|
Portugal |
Cross-sectional |
Resident doctors of various specialties |
Modified PHEEM |
Medical residency for all specialties and regions of Portugal |
To evaluate the doctors’ satisfaction with residency according to specialty and region of the country. |
3456 |
91.7(24.2) |
Not reported |
Absence of sexual and racial discrimination, good collaboration with other doctors, opportunity to participate in educational events. |
Lack of protected time for study, lack of counseling opportunities for failure situations, lack of adequate accommodation during shifts, little career advice. |
Modified PHEEM including questions about satisfaction with coordination and advisor. Endocrinology, Cardiology, Anesthesiology, Family Medicine and Gastroenterology were the specialties with the greatest satisfaction. Greater satisfaction among residents of Azores and Madeira. |
Binsaleh et al, 201530
|
Saudi Arabia |
Cross-sectional |
Urology residents |
PHEEM |
Urology residents, different training levels, in several regions of Saudi Arabia and in different sectors of the healthcare system. Only 1 woman. |
To investigate associations with level of training, regions of Saudi Arabia, and healthcare system sectors. |
38 |
77.7 (16.5) |
A: 26.18 (6.5) |
Absence of racism, feeling part of the team, opportunity to participate in educational events, accessible teachers. |
Food during shifts, lack of clinical protocols and information manuals for residents, lack of contract regarding working hours. |
Less than satisfactory educational environment. Differences between different healthcare sectors. Perception did not vary between training level and regions of the country. Need to improve: clinical protocols, working hours, quality of supervision, infrastructure in the hospital environment. |
T:29.7 (7.7) |
S: 21.9 (4.3) |
BuAli et al, 2015 31
|
Saudi Arabia |
Cross-sectional |
Residents in Pediatrics |
PHEEM |
Six teaching hospitals in the eastern region of Saudi Arabia |
To evaluate the educational environment of the pediatric residency in 6 hospitals. |
104 (37 women , 67 men) |
100.19 (23.13) |
A: 34,91(7,83) |
Collaboration with other residents, feeling part of the team, possibility of participating in educational events, opportunity to perform practical procedures. |
Racism, sexual discrimination, working hours, food during shifts, culture of blame, having to perform inappropriate tasks and being called at inappropriate times. |
There was no significant difference between genders and year of training. Differences were observed between hospitals. Improvement in social support is required, especially regarding issues of racial and sexual discrimination. |
Women: 105.39 (22.16) |
E: 38,89(9,8) |
Men: 97.23 (23.48) |
S:26,38(7,04) |
|
Women: A: 38.5 (7.98) |
T: 38.88 (8.14) |
S: 28 (7.69) |
Men: A:35.86 (7.75) |
T: 35.98 (10.75) |
S:25.38 (6.56) |
Chew et al, 20228
|
Singapore |
Longitudinal |
Psychiatry residents |
PHEEM , OLBI |
Singapore National Psychiatry Program |
To evaluate the relationship between burnout and the educational environment among psychiatry residents each year for five years. |
93 |
Initial : 112.3(16.2) |
Initial : A:39.2(5.8) |
Not reported |
Not reported |
Perception of the baseline educational environment was inversely proportional to the burnout status. The PHEEM teaching subdomain score increased significantly over time for all residents regardless of the burnout status. |
After 5 years: 120.3(14.0) |
T:43.3(6.4) |
S:29.6(5.1) |
After 5 years: A:42.0 (5.4) |
T:47.0(4.8) |
S:31.4(4.6) |
Clapham et al, 2007 32
|
Egland nd Scotland |
Cross-sectional |
Intensive care residents |
PHEEM |
Nine intensive care training centers in hospitals in England and Scotland. |
To demonstrate the quality of the residents’ work environment. |
134 |
103.5 (19.1) |
A: 35.7 (7.03) |
Absence of racism or sexism, good supervision, collaboration with other residents, adequate level of responsibility, feeling like part of the team. |
Food and accommodation during shifts, lack of information manual for residents, lack of opportunity for counseling for residents who failed. |
There was a significant difference between training level and between centers. No racism or sexual discrimination was reported. Residents satisfied with teaching, work and social support. |
T:38.8 (9.46) |
S: 28.43 (5.20) |
Ezomike et al, 2020 33
|
Nigeria |
Cross-sectional |
Residents of internal medicine, gynecology, pediatrics and surgery. |
PHEEM |
Nigeria University Hospital. |
To evaluate the educational environment and determine if there are differences in subgroups of residents. |
160 |
85.82 (1.02) |
A:29.27 (1.05) |
Collaboration from other residents, absence of sexual discrimination, opportunity to participate in educational events, appropriate level of responsibility. |
Food during shifts, accommodation during shifts, lack of counseling opportunities for residents who failed, excessive working hours |
The perception of social support is that the environment is not pleasant. Men scored higher than women and gynecology and obstetrics residents scored higher than those from other specialties in the total PHEEM score and in the teaching and social support categories. There was a difference between training levels in the total score and autonomy subscore. |
T:34.80 (0.98) |
S: 21.55 (1.03) |
Fisseha et al, 2021 34
|
Ethiopia |
Cross-sectional |
Internal medicine residents |
PHEEM |
University Hospital in Ethiopia. |
To evaluate the educational environment in an internal medicine residency program in Ethiopia. |
100 (80 men) |
70.87 (19.8) |
A:25.9 (7.1) |
Collaboration from other residents, absence of racism and sexual discrimination, feeling physically safe in the hospital environment. |
Food and accommodation during shifts, lack of manual and clinical protocols for residents, lack of feedback from teachers, lack of supervision at all times, excessive workload. |
The total PHEEM score indicates many problems and the need for changes. Main problems to be improved: excessive workload, inadequate teaching, inadequate physical hospital environment and lack of diagnostic and therapeutic resources. The score was higher for men than for women. |
T:27.1 (10.2) |
S:17.9 (5.1) |
Flaherty et al, 2016 35
|
Ireland |
Cross-sectional |
Residents of various specialties |
PHEEM |
University Hospitals in Galway, Ireland |
To assess the educational environment among residents of different training levels in Ireland. |
61 |
82.88 (18.99) |
A: 27.83 |
Absence of sexual and racial discrimination, feeling part of the team, collaboration with other residents, feeling physically safe in the hospital. |
Excessive workload, calls at inappropriate times, poor food and accommodation during shifts, lack of protected time for study, lack of feedback from preceptors, culture of blaming the resident. |
Deficiencies were identified in several aspects of the educational environment including the need to improve protected study time, feedback, and learning opportunities for doctors in the initial years of training. |
T: 31.19 |
S: 23.75 |
Galli et al, 201436
|
Argentina |
Cross-sectional |
Residents of Cardiology |
PHEEM |
31 hospitals (public and private) in the Buenos Aires region |
To evaluate the educational environment in Cardiology residency and compare public and private hospitals. |
148 |
Not reported. |
Not reported. |
Feeling part of the team, opportunity to work as a team, absence of sexual and racial discrimination. |
Lack of protected time for study, lack of a manual with instructions about the program, lack of clear rules. |
More positive than negative educational environment, but with room for improvement. Private hospitals showed better teaching conditions. |
González et al, 2022 37
|
Chile |
Cross-sectional |
Residents from 64 specialties |
PHEEM |
15 universities in Chile |
To evaluate the educational environment of residency programs in different specialties. |
1259 |
100.5 |
A:36.0 |
Not described. |
Lack of protected time for study, culture of blaming the resident and lack of a routine manual. |
The specialties with the highest PHEEM scores were: Ophthalmology (116), Dermatology (113.5) and Anatomopathology (113) and those with the lowest scores were General Surgery (82) and Gynecology, Obstetrics (88.5) and Cardiology (92). |
T:38.0 |
S26.0 |
Goughet al, 201038
|
Australia |
Cross-sectional |
R1, R2, and R3 Residents |
PHEEM |
9 hospitals |
To test PHEEM acceptability. |
429 |
110 |
Not reported. |
Available teachers, safe environment and teamwork. |
Food during shifts, lack of feedback, little career guidance. |
8 hospitals: more positive than negative environment, and 1 hospital: excellent environment. |
Goul-ding et al, 201639
|
United Kingdom |
Cross-sectional |
Dermatology Residents |
Modified PHEEM |
Hospitals located in one region of the United Kingdom (West Midlands) |
To evaluate the educational environment in the Dermatology residency. |
19 |
96.5 / maximum score of 152 |
A: 35.8/56 |
Possibility of participating in educational events, safety in the workplace, teachers with good teaching skills |
Accommodation and food during shifts, lack of feedback from teachers, few opportunities for counseling in case of poor performance. |
Questions about sexual and racial discrimination were excluded. |
T:39.4/60 |
S:21.3/36 |
Herrera et al.2012 6
|
Chile |
Cross-sectional |
Residents from several specialties (35 programs) |
PHEEM |
Several clinical, surgical and pediatric specialties. |
To compare scores by gender, university, nationality. |
318 |
105.09 (22.46) |
A: 36.54 (8.26) |
Low discrimination, good preceptors, safe environment. |
Lack of time to study, little academic advice, lack of information about working hours. |
There was no difference between gender and university of origin. Foreigners rated the educational environment better than Chileans. |
T:39.76 (10.11) |
S:28.79 (5.98) |
Jalili et al, 2014 40
|
Iran |
Cross-sectional |
Emergency medicine residents |
PHEEM |
Three emergency medicine programs |
Applicability of the Persian version of the questionnaire. |
89 |
Did not evaluate the total average |
Evaluated average per item. Average score per item 2.24 (0.06) |
Working hours contract, accessible teachers, teamwork. |
Lack of information manual, accommodation during shifts, career guidance. |
Persian version with 37 questions and not 40. Reliable method for emergency medicine programs. No differences between genders and training levels. |
A: 2.4(0.58) |
T: 2.57(0.35) |
S:2.21 (0.67) |
Karatanos et al, 201541
|
Greece |
Cross-sectional |
Residents of several specialties. |
Modified PHEEM |
Western Greece Hospitals |
To evaluate the educational environment in hospitals in different specialties. |
731 |
Not described. |
Not described. |
Teamwork, accessible teachers, encouragement to learn alone |
Racism and sexual discrimination, lack of feedback, lack of information manual, lack of support for residents with poor performance. |
Modified PHEEM with the inclusion of 10 extra closed questions and one open question. Resident doctors are not satisfied with the educational environment of Greek hospitals. |
Khan et al, 2017 42
|
Pakistan |
Cross-sectional |
Residents of Internal Medicine, Pediatrics, Gynecology and Obstetrics, General Surgery. |
PHEEM |
Mirpur City Teaching Hospital, Pakistan |
Evaluate the educational environment of medical residency programs. |
82 |
90.7(15.6) |
A; 30.2(5.9) |
Not described . |
Not described. |
Higher scores in the teaching and autonomy subscores. The specialty with the highest score was Internal Medicine followed by Pediatrics. |
T:38.9(7.1) |
S:21.6(5.8) |
Khoja, 2015 43
|
Saudi Arabia |
Cross-sectional |
Family medicine residents |
PHEEM |
Family medicine residents from 4 centers |
Assess the educational environment and differences between genders, training level and hospital center. |
91 |
67.1 (20.1) |
A: 24.2(7.1) |
Safe environment, without racial discrimination, teachers encourage independence. |
Accommodation and food during shifts, lack of career guidance, excessive workload. |
Very low overall score. There was a difference between the centers. More advanced residents have higher scores. There was no significant difference between genders. |
T: 25.31(8.9) |
S:17.59 (5.6) |
Koutso-giannou et al, 201544
|
Greece |
Cross-sectional |
Residents of various specialties |
PHEEM |
Residents of 83 hospitals and 41 city halls |
Validation of the instrument, Greek version with 6 response degrees. |
731 |
Not assessed |
Not assessed |
Absence of racial and sexual discrimination, good collaboration between doctors, accessible teachers. |
Lack of career guidance, lack of information manual for residents, poor feedback. |
Greek version is valid, reliable and sensitive for evaluating educational environment. |
Llera et al, 2014 45
|
Argentina |
Cross-sectional |
Residents in pediatrics, internal medicine, family medicine, cardiology, intensive care |
PHEEM E MBI |
Residents of 5 medical residency programs |
Correlates the educational environment and burnout |
92 |
106.8 (13.98) |
A:36.57 (5.69) |
Not reported. |
Not reported. |
19.6% burnout. Negative correlation between the educational environment and exhaustion and depersonalization. Positive correlation between educational environment and personal fulfillment. Correlation between burnout and PHEEM autonomy subscore |
T:39.79 (6.19) |
S:30.48 (2.48) |
Mahen-dran et al, 201346
|
Singapore |
Cross-sectional |
Psychiatry residents |
PHEEM |
Two residency models: British and American |
To compare the PHEEM results in the 2 residency models |
60 |
109.30 |
Worst scores on the teaching subscale |
Absence of racial and sexual discrimination, protected study time, absence of inappropriate tasks |
Lack of clear expectations, lack of teaching skills by teachers, few learning opportunities. |
There was no difference in PHEEM between the 2 residency models. Worst scores on the teaching subscale |
Ong et al, 201947
|
Singapore |
Cross-sectional |
Internal medicine residents |
PHEEM |
Internal Medicine Program |
To assess educational environment, compare results by gender and training level, and evaluate areas for improvement. |
136 |
112.2 (16.7) |
A: 38.5(6.18) |
No racial and sexual discrimination, feeling of belonging to the team, good collaboration with co-workers. |
Excessive workload, little contact with teachers and lack of feedback, lack of adequate food during shifts. |
There was no difference between genders and training levels. |
T: 42.79 (6.49) |
S:30.93(5.07) |
Papaefstathiou et al, 2019 48
|
Greece |
Cross-sectional |
Resident doctors (surgery, internal medicine and laboratory) |
Greek version of PHEEM, CBI, JSM |
Several hospitals in Greece. |
To evaluate the relationship between the educational environment and professional stress with the development of burnout. |
269 |
46.26 (14.54 ) |
A: 42.09 (16.36) |
Not reported |
Not reported |
Different scoring in the Greek version of PHEEM (0-100): 0-25: very negative; 26-40: negative; 41-50: more negative points; 51-60: more positive points; 61-75: positive; 76-100: very positive Educational environment has more negative points than positive points in total and in the 3 subscales. The total PHEEM score and the 3 subscales correlated negatively with burnout (CBI). Positive correlation between stress level and burnout and personal exhaustion. |
Greek version - different scoring system (41-50: more negative points). |
T: 46.8 (19.51) |
S: 49.59 (14.33) |
Greek version - different scoring system (41-50: more negative points). |
Pinnock et al , 2009 49
|
New Zealand |
Cross-sectional |
Pediatrics residents |
PHEEM |
Pediatrics residents attending early and advanced residency years. |
To evaluate the educational environment of pediatric residency in New Zealand. |
53 |
Early years: 106.3 (18.3) |
Early years: A; 37.4(6.3) |
Feeling part of the team, teachers with good teaching and communication skills, absence of racism and racial discrimination, adequate levels of responsibility. |
Accommodation during shifts, few opportunities for counseling for residents with difficulties, lack of information manual and guidance. |
Residents in more advanced years evaluated the educational environment better than residents in the early years. |
Advanced years; 114.2 (17.8) |
T:39.6(8.7) |
S:29.4(5.7) |
Advanced years: A:39.5(5.7) |
T:44.1(8.1) |
S:30.5(5.5) |
Posada Uribe et al, 2021 50
|
Colombia |
Cross-sectional |
Residents of clinical and surgical specialties |
PHEEM and WEMWBS |
Residents of clinical and surgical specialties |
To determine the relationship between the educational environment and well-being |
131 |
107.96 (18.88) |
Not reported. |
Not described |
Not described |
Positive correlation between educational environment and assessment of well-being through two scales. |
Puranitee et al, 2019 51
|
Thailand |
Cross-sectional |
Pediatrics residents |
PHEEM, MSI, WRQoL |
Department of Pediatrics at a hospital in Bangkok |
To evaluate the association between burnout and the educational environment and work-related quality of life |
41 |
112.7 (11.2) |
It does not describe the average. |
Not described. |
Food during the shifts (mentioned as the item with the lowest PHEEM score) |
Emotional exhaustion and educational environment correlate with quality of life at work. Positive correlation between educational environment and quality of life in the workplace. Considers that PHEEM may not be the appropriate instrument to assess the educational environment in Thailand. |
A: 88% - positive perception |
T: 51% more positive than negative points, but needs improvement (scores between 31-45) |
S: 85% more positive than negative points |
Sandhu et al, 2018 52
|
Pakistan |
Cross-sectional |
Resident doctors from different specialties (internal medicine, general surgery, gynecology and pediatrics) |
PHEEM |
Hospital in the city of Lahore, Pakistan. |
To determine the quality of residents’ educational environment. |
87 |
90.49 (15.4) |
A: 30.16 (5.85) |
Adequate level of responsibility, teachers with excellent communication and teaching skills, collaboration with other residents, team feeling |
Non-compliance with working hours (highlighted as the lowest scoring item), food during shifts, accommodation during shifts, lack of time reserved for study. |
Highest score for the neurology department and lowest score for anesthesiology. 71.3% of residents classified the work environment as “more positive than negative, but with room for improvement”. |
T: 38.87 (7.03) |
S: 21.45 (5.75) |
Sheikh et al, 2017 53
|
Pakistan |
Cross-sectional |
Resident doctors |
PHEEM |
One public hospital and 6 private hospitals in Karachi, Pakistan |
To evaluate the educational environment of residency programs and identify differences between public and private sectors of tertiary hospitals. |
302 |
93.96 (20. 79 ) |
A: 32.83(7.34) |
Good collaboration from other residents, teachers with good teaching skills, adequate level of responsibility. |
Food during shifts, access to a document listing the skills expected of residents, calls at inappropriate times. |
Total PHEEM score was significantly higher in private hospitals than in public ones. Slightly modified version to better meet regional issues, for example appropriate workload (there is no national regulation). |
T: 37.27(9.43) |
S: 23.97(6.76) |
Shimizu et al, 2013 54
|
Japan |
Cross-sectional |
Resident doctors |
PHEEM and GM- ITE |
21 teaching hospitals in Japan |
To evaluate the relationship between the educational environment and the residents’ medical knowledge assessed by an exam at the end of residency. |
206 |
57.6(5.4) |
Not reported |
Not reported |
Not reported |
Medical knowledge was significantly associated with the educational environment of hospitals. The presence of an internal medicine department and a rural location were associated with a higher score. |
Vieira,20087
|
Brazil |
Cross-sectional |
Residents of internal medicine, anesthesiology and general surgery (HC) and various specialties (HGCR). |
PHEEM |
Hospital das Clínicas de São Paulo and Hospital Governador Celso Ramos (Florianópolis) |
To validate the use of PHEEM translated into Portuguese and evaluate the reliability of its use. |
306 |
Not assessed |
A: 33.9 (8.6) |
Absence of racism and sexual discrimination, adequate level of responsibility, accessible teachers, opportunity to practice procedures. |
Food during shifts, non-compliance with workload, absence of specific periods for studying, lack of feedback from teachers, lack of culture of not blaming the resident. |
Highlighted the importance of improvements in the main factors related to the perception of teaching (feedback, study period). Use of PHEEM is reliable to assess educational environment. Greater autonomy for internal medicine residents. Higher score in the perception of teaching by the anesthesiology residents. It perceived similar social support in the three areas. |
T: 35.0 (10) |
S: 26.6 (6.0) |
Waheed et al, 201955
|
Pakistan |
Cross-sectional |
Gynecology and obstetrics residents |
PHEEM |
All gynecology and obstetrics residency programs in Lahore (11 institutions - 5 private and 6 public ones). |
To determine the quality of the educational environment for GO residents. |
368 (only 4 men) |
63.68 (29.6) |
A: 23.94 (10.28) |
They feel satisfied with their work, adequate working hours, food during the shift. |
Teachers lack communication skills, little collaboration from other residents, and lack of clinical supervision at all times. |
The majority of residents classified the educational environment as having “many problems”, highlighting the need for improvements. Higher PHEEM scores in public hospital residents. |
T: 20.16 ( 11.9) |
S: 18.42 ( 8.04) |