Learning communities (LCs) have been shown to be effective in a variety of educational settings from kindergarten to graduate and professional schools.1,2 LCs are based on the perception, attributed to Dewey, that education is most successful as a social process.3,4 Formal LCs are most often subgroups or cohorts of students who share a common purpose, similar interests, and learning experiences. Learners and their learning are the central focus of LCs, which have been categorized as (1) curricular, (2) classroom, (3) residential, and (4) student type.5 Student-type LCs generally focus on student development and engagement or connection. For example, in a medical school setting, a student-type LC might focus on career education and advising activities; service learning; leadership and professionalism development activities; social functions, including athletic and cultural activities; and intentional peer-to-peer educational and social interactions, especially between upper and lower classmen (vertical integration among classes). In other words, student-type LCs can be viewed as an attempt to formalize and manage the “informal curriculum.”
Although one or more types of LCs can now be found in most colleges and universities, medical schools, with a few exceptions, have only recently incorporated LCs, particularly student-type LCs, as an integral part of the medical school student experience. Thus, although there is a growing body of literature documenting the benefits of LCs in higher education, very little is known about the efficacy of LCs in medical schools. Benefits to students noted in the available literature include higher academic achievement, better retention rates, greater satisfaction with college life, improved quality of thinking and communication, a better understanding of self and others, and a greater ability to bridge the gap between the academic and social worlds.1
Although several medical schools have instituted LC structures in the last five years, little has been published examining the outcomes of incorporating LCs into the medical school environment. Our purpose is thus to present the results of a prospective evaluation of medical students’ perceptions of emerging LCs and their impact on medical student life at the University of Iowa. Specifically, our evaluation sought to examine students’ interactions within and outside of their medical school class and the activities in which they participate, and whether the establishment of LCs changed students’ perceptions of their learning environment. In addition, we sought to identify students’ perceptions of benefits and concerns related to the LCs.
LCs at the Carver College of Medicine
During the early 1990s, administrators at the University of Iowa Roy J. and Lucille A. Carver College of Medicine (UICCOM) recognized the need for major changes in how medical education was delivered to students. Accordingly, they initiated an intensive review and revision of the curriculum and began planning for a new medical education building. As plans for the “new curriculum” were discussed and solidified by the faculty, a new student management model (later known as the LCs) was envisioned that would provide increased student services and development opportunities consistent with curricular goals. Dedicated space was designated and developed for four student-type LCs in a new medical education building designed to accommodate the LC format. The final recommendation for the new student management model (LCs) included five goals, later encompassed in the acronym CELLS, standing for Connection, Excellence, Learning, Leadership, and Service. The intent was for the LCs to encourage students to connect with other students, faculty, and staff on a more intimate level; support and encourage students to excel in the pursuit of academic success, personal growth, career decisions, and professional development as competent physicians; create opportunities for students to enhance and exercise their leadership skills; foster a supportive environment for formal and informal learning; and involve and interest students in service efforts that have a positive impact on the health and well-being of the community and larger society.
As the building neared completion and the new curriculum became well established, each current student (and each entering student in subsequent years) was randomly assigned to one of the four LCs for the duration of his or her medical school experience. Each LC included one fourth of the students in each class, providing an equal number of first- through fourth-year students, MD/PhDs, and physician assistant students in each LC. Staff resources allocated to each LC included a faculty director (25% FTE), coordinator (40% FTE), and secretary (5% FTE). Overall direction of the LCs was provided by an assistant dean.
We collected evaluation data in 1999 when the concept of LCs was first introduced to students at the UICCOM and again in 2003 when students had experienced a full year of full integration of LCs into the college and within the new medical education building. A two-page questionnaire assessed connections among students within and between classes, students’ participation in various activities, and anticipated/perceived benefits of LCs, concerns about LCs, and the students’ perceptions about the impact of LCs on the learning environment. Measuring these data allowed us to evaluate the progressive implementation of LCs and their impact on students’ perceptions and activities over time.
Administration of surveys
We distributed hard-copy surveys to all 508 second- through fourth-year medical students, including MD/PhD students, in late September 1999 via student mailboxes. In late September 2003, surveys were distributed by e-mail to all 433 students. In an attempt to maximize response rates, after initial distribution of the surveys, we sent students two reminders asking them to complete the surveys: once before the original deadline and once after the deadline had passed. First-year students were excluded from this study because they would have little basis on which to respond to the survey, having only been in medical school for four to six weeks at the time of survey administration.
Connections among students.
This was primarily measured by asking students to estimate the number of classmates they could name outside of their own medical school class. Students estimated the number of students they could name in each of the four classes, including their own, by filling in blanks for each class year. We assumed that if they could name particular students within their own medical school class and outside of their own medical school class, it would indicate that they had had significant interaction with them. We also asked students to identify the contexts in which they had gotten to know students from their own class as well as those outside of their classes. Choices included student organization or committee, classroom activities, medical fraternity, and through friends. In 2003, LC activities was added as an option.
Student activities involvement.
We measured this aspect by asking students to identify the frequency of their participation in activities during the previous year. These activities included community service projects, school-related social functions, and fine arts activities. In the 2003 survey, we also added an item asking about frequency of participation in LC activities.
These were measured by adding a question in 2003 asking students to identify the extent to which LCs were perceived as contributing to
- (1) seeking advice from upperclassmen
- (2) professional development, and
- (3) meaningful interaction with faculty
Scale response choices included “not at all,” “somewhat,” and “quite a bit.”
Perceptions of the learning environment.
The learning environment refers to the broad physical, social, and psychological context in which students learn, including the quality of interactions with students, staff, and faculty; the curriculum; available facilities; and so forth. LCs are organizational structures within learning environments and can contribute to the perceived quality of the learning environment. Perceptions of the learning environment were assessed using a modified version of the Medical School Learning Environment Scale (MSLES).6 The MSLES was originally designed to assess seven related dimensions of a learner’s perceptions of the learning environment. To encourage an adequate response rate and to obtain a global measure of the learning environment, we modified the 55-item scale to a 17-item scale, selecting specific scale items reflecting the primary objectives of UICCOM’s LCs. Students responded to the prompt to “choose the category of frequency that most closely approximates your perceptions of the learning climate at the UICCOM.” Responses were presented in a five-point Likert scale, where 1 = never, 2 = seldom, 3 = occasionally, 4 = fairly often, and 5 = very often.
The 17 MSLES questions we abstracted related to breadth of interest, student–student interactions, meaningful learning experiences, organization, and supportiveness. We also added a question about vertical integration of students, not part of the original MSLES, to the scale. A factor analysis of these 17 items resulted in somewhat different groupings of the items for this study. Table 1 displays definitions of the constructs, the subscales derived from the 17 items, and the alpha reliability coefficient for each subscale.
Perceptions of LCs.
We made a qualitative assessment of students’ perceptions using open-ended questions. Students responded to the following questions: (1) What are you excited about in regard to LCs? (2) What concerns do you have regarding LCs? and (3) Do you have any suggestions for how LCs can involve more students like you? In 2003, the open-ended question, “What benefits do you see in being part of a LC?” was added.
Our data analysis employed descriptive, parametric, and nonparametric statistical methods. Likert scale values were assessed and statistical significance was examined using t tests and χ2 tests with P set at .05 for statistical significance. Seven items (6, 8, 9, 10, 14, 15, and 17) on the adapted 17-item MSLES scale were phrased negatively and, hence, were reversed for the analysis so that higher values represented a more positive evaluation of the learning environment.
Analysis of open-ended comments was facilitated by entering all comments, categorized by year and medical school class, into a database in Nvivo (Victoria, Australia: QSR International, Inc.), a qualitative analysis software that allows for systematic coding and searching of narrative data for recurrent concepts and themes. We developed codes based on overall objectives of communities, variables measured in quantitative items, and themes arising directly from reading the narrative comments. Salient categories and themes were then identified on the basis of the most common responses from learners.
In 1999, the response rate was 59% (299/508), and in 2003 it was 67% (289/433). The smaller number of eligible students in 2003 is attributable to a decrease in the number of students admitted for the fall of 1999 and subsequent years.
Connections among students
In response to the question regarding how many students outside of his or her own class each student knew, significant differences were found between the two observation periods, with a higher percentage of students from outside of a given class reported for 2003 (Figure 1). To correct for differences in the overall number of acquaintances across students named, we added the number of students they could name within their own class and the number they could name outside of their class, and then we calculated the percentage of those acquaintances that were from outside the student’s class. In 1999, students tended not to know many students outside their own class, with a particularly striking gap between second-year preclinical students and third- and fourth-year clinical students. For the 2003 study period, there was a significant increase in the average percentage of acquaintances students could identify who were from outside of their own class, including between preclinical and clinical students. Specifically, the overall average percentage of students that could be named outside of each student’s class increased, with the average being 25% in 1999 and 31% for 2003. In regard to specific classes, the percentage of students who could be named outside their own classes increased significantly for both second-year students (26% in 1999 versus 33% in 2003) and third- and fourth-year students (25% in 1999 versus 30% in 2003), based on t tests for significant differences between means.
Students were also asked to identify the context in which they had met these students outside of their own class (Table 2). All of the contexts identified in the survey instrument where students could indicate meeting other students not in their own class showed a significantly positive increase from 1999 to 2003. The one exception was the category “through friends,” which decreased as a context where students met others outside their own class. In 2003, 78 students (27% of respondents) identified LC activities as a context in which they met students outside their own class.
Student activities involvement
We examined students’ participation in various activities across the observation periods (Table 3). Reported participation in community service projects or volunteer services was significantly greater in 2003 than in 1999. Participation in school-related social functions and fine arts activities significantly decreased from 1999 to 2003. Because the majority of school-related social functions and fine arts activities in 2003 occurred under the auspices of LC sponsorship, these negative findings may reflect students’ perception of these questions as only asking about activities outside of LC social and fine arts activities.
To assess students’ overall level of engagement in LCs, we constructed a variable that combined participation in community service projects, fine arts activities, and other LC activities. To control for the fact that there were no LC activities in 1999, we took the mean across all three categories, and then we created a categorical variable of low, moderate, and high engagement. Figure 2 demonstrates that there was a significant gain in overall level of engagement from 1999 to 2003 for third- and fourth-year students as well as for second-year students (χ2 test significant at P < .01).
In 2003, students responded to objective questions regarding the contribution of LCs to specific aspects of student development. These questions were not included in the survey during 1999, because the LCs were not well established at that time. Responses for the extent to which communities contributed to the areas of (1) seeking advice from upperclassmen, (2) professional development, and (3) meaningful interaction with faculty are presented in Figure 3 by class. Overall, more than 50% of students perceived that LCs contributed somewhat or quite a bit to these areas of their experience. However, a substantial number of respondents indicated that LCs had no impact on these areas. When analyzed by class, second-year students perceived LCs as having more impact on these areas than third- or fourth-year students.
Perceptions of the learning environment
Assessment of the learning environment via the MSLES measured students’ overall positive or negative perception of the learning environment. The sample of items was drawn from scale measures of seven dimensions of the MSLES that are all related in some way to the overall learning environment. To ascertain whether these dimensions were sufficiently interrelated to provide a measure of overall perceived quality, we calculated an alpha statistic to examine the interrelatedness of the items. The total score from the 17-item instrument achieved an α level = .84. This demonstrates that a highly consistent measure of the overall perception of the learning environment was being obtained and that the items were highly interrelated.
Table 1 compares students’ assessments of the learning environment between 1999 and 2003. Significant differences demonstrating higher mean scores in 2003 than in 1999 included differences in the sum of the total group (second-, third-, fourth-year, and MD/PhD students) across the two periods. Significant increases in overall perception of learning environment indicators were found in analysis by medical school class for second-year and fourth-year students. Overall learning environment indicators comparing third-year students across years revealed no significant differences.
Analysis of each subscale for each observation group across years revealed significant differences for three of the five subscales we expected to change, with higher scores in 2003 than in 1999. These included scales measuring breadth of interest, supportiveness, and vertical integration. There were no significant differences between observations for scales measuring meaningful learning experiences and organization, which was an expected outcome for these measures because they focused on aspects of the learning environment that were not anticipated to have been affected by LCs. There were also no significant differences across observations for the two subscales measuring the student–student interaction.
Perceptions of LCs
Students provided narrative responses to open-ended questions specifically addressing the perceived benefits, opportunities, and concerns associated with LCs. Mirroring the analysis used for the quantitative measures, our qualitative analysis of student comments were examined and compared across the two observation periods.
We first analyzed students’ comments using iterative theme analysis7 to identify the most salient themes. A second level of analysis examined the relation of students’ comments to the main goals of the LCs (connection, excellence, leadership, learning, and service). There was significant crossover between the salient categories identified in our general thematic analysis and the more specific analysis of comments related to LC goals. Therefore, results are presented using the LC goals as a framework. Representative comments are presented in List 1.
Student comments related to LC objectives.
Students’ comments varied significantly in tone across the two observation periods. In particular, in 1999, most comments focused on the potential of LCs rather than actuality because little beyond community assignments and intramural activities had been established. Many student comments in 1999 emphasized not having a clear idea of what LCs were and how they would work and intersect with existing IUCCOM structures, activities, and student relationships. In contrast, comments in 2003 were more grounded in students’ actual experiences with and awareness of LC activities, as well as their physical placement and integration into the new medical education building.
The majority of student responses, both in regard to benefits and concerns, were related to opportunities for connections with classmates and students in other classes. In particular, one of the benefits cited most often by students in both observation periods and across years was the potential for increased vertical integration between classes. Comments from 1999 focused on the potential for more interaction between classes; this shifted to an emphasis on actual increased interaction between classes that was seen as a result of LCs in 2003. Other salient comments centered around the perception of more opportunities for general interaction within classes and communities, creating what were perceived as smaller and less intimidating group interaction opportunities. Finally, a limited number of comments focused on having greater opportunities for connecting with faculty and staff, particularly those with direct responsibilities within the LCs, such as the LC directors. The concept of vertical integration was also a focal point of concern expressed by students across the two data-collection periods. Although concerns as to whether interaction could be increased were less frequently expressed in 2003, students in 2003 did express concerns about conflicting course schedules of M2s versus M3s and M4s as an obstacle to integration. Upperclassmen across both observation years consistently indicated their belief that LCs would be of more benefit to first- and second-year students, who had more physical access and time to participate in LC activities. Other consistent student concerns were related to perceived lack of time for participation and wanting more participation from faculty.
Students’ comments related to mentoring, having access to faculty and upperclassmen as role models, and perceptions of supportive and accessible faculty and staff indicate that students perceived LCs as contributing to excellence as previously defined. Comments across the two observation periods consistently referred to having access to upper classmen for mentoring and advice. Particularly in 2003, students also mentioned appreciating faculty involvement in LCs and having more opportunity to interact with faculty in informal settings. Students did express concerns, especially in 2003, that they wanted more faculty involvement in the LCs. Newer efforts (e.g., a program that provides periodic meetings with a faculty mentor during the clinical years) were noted by some students as a positive step in this direction. Several students also mentioned benefiting from greater accessibility to staff and their interest in supporting and responding to the needs of students.
Some students mentioned that LCs create the opportunity for students to be involved in leadership, and some even more specifically addressed new leadership opportunities as a benefit created by the LC structure. Other student comments noted increased responsiveness on the part of the UICCOM administration to student-initiated activities and input into the LC structure.
Few specific comments were made regarding learning and curricular opportunities created by LCs. However, many student comments addressed the benefits of being able to learn from upperclassmen; likewise, upperclassmen commented on opportunities to provide guidance to preclinical students. Students did note an appreciation for the additional scheduled learning opportunities sponsored by the LCs on topics that were not included in the formal curriculum but were of general interest to medical students. Many students, especially in 2003, noted how the physical existence of communities provided space that enhanced their learning and studying ability. In addition, upperclassmen expressed some excitement about being able to help other students, including underclassmen.
Another often-noted benefit of LCs was the potential for and actual increase in opportunities for service within the college as well as in the broader community. For some students, this was perceived as one of the main benefits of LCs and echoes the concept that LCs provide more opportunities to get involved. In addition to comments about connections and interaction, and about the physical space, community service was identified as one of the major benefits. Students’ comments shifted from noting the potential for service activities in 1999 to citing specific service activities such as the student-initiated mobile clinic during 2003.
Lack of participation in LCs.
Our analysis of students’ comments helped to identify reasons that some students did not participate in or perceive benefit from LCs. Individual lack of participation was noted more consistently by third- and fourth-year students than by second-year students. The most frequent reasons for nonparticipation cited by upperclassmen were LC activity conflicts with their busy schedules, lack of support from clinical clerkship residents and faculty to allow students to participate in LC activities, distance of the site of clinical clerkships from the building in which most community activities (both informal and formal) occurred, and preferring to spend their limited free time with family and friends outside of the medical school. Upperclassmen consistently noted that for many of these reasons, they perceived that LCs were of most benefit to first- and second-year students.
Our analysis of students’ perceptions of LCs from implementation through integration, including moving into a new building with designated LC spaces, has demonstrated changing perceptions among students. Most significant in our findings are the ways in which LCs have created opportunities for connection and interaction between students, both within and outside of their class. Also, enhanced opportunities for leadership, service, and engagement stand out as a positive outcome. Between 1999 and 2003, more students availed themselves of these LC opportunities, mirroring the increase in available opportunities. Both quantitative and qualitative measures demonstrated that not all students perceived these benefits and that participation in LC activities was variable. Some students attributed this variation to need; for example, if they already felt they had sufficient connections, they may have been less interested or willing to participate. The biggest difference in terms of perception of benefit and participation was between second-year students compared with upperclassmen. Time and scheduling conflicts that hamper participation in community activities were noted as a consistent challenge in students’ comments. Overall, students’ perceptions of LCs changed significantly and in a positive direction with greater implementation of the LCs.
Negative and nonsignificant findings in comparing the two cohorts we examined can be explained at least partially by the focus of LCs at UICCOM. For example, because the UICCOM LC is a student-type LC, focusing on student development and engagement, little difference was noted in students’ perceptions of the learning environment related to curriculum and learning. Another possible explanation is that the learning environment instrument (MSLES) on which our survey was based has traditionally been used to determine and compare medical students’ responses to curricula and curricular changes rather than paracurricular innovations such as LCs.6,8 In addition, we included some negatively stated items directly from the MSLES. However, because we designed our survey in 1999, concern about the validity of using negative items on the MSLES and similar instruments and then simply reversing the numbers has surfaced in the literature.8 This could help explain unexpected nonsignificant differences, especially in relation to the student–student interaction subscale. Nonsignificant differences in the student–student interaction subscales may also be attributable to the already high mean for these scales in the first observation period. Although overall student engagement in LC activities significantly increased between 1999 and 2003, student-reported participation in social and fine arts activities decreased. These findings are most likely attributable to students’ interpretation of the survey questions. Specifically, because most social and fine arts activities were subsumed under the LC structure, students may have been reporting only participation in non-LC activities. These findings and students’ comments demonstrate that a minority of students did not participate in these activities either before or after the implementation of LCs.
This study has several limitations. Because not all students responded to the surveys, and because we did not gather identifying material, it is not clear who the respondents were in each survey administration. It is possible that the majority of respondents may have been those students who had been most actively involved in communities and/or those who had especially negative feelings. Data collection in 2003 occurred only after LCs had been fully integrated into the physical space for one year. Whereas the fourth-year students we surveyed had been exposed to the LC concept from the beginning of their education at UICCOM, all of the respondents had experienced LCs outside of the fully integrated format within the building and during times when their potential and purpose may have been less clear. In addition, because of the timing of the two observation periods, student respondents in each observation period represented a completely different cohort of students with quite different experiences of LCs and the learning environment. We know of no other prospective study of medical student perceptions of the effects of LCs on the learning environment that captures changes in perceptions over time. In the future, we will continue to collect data to provide comparisons with students who have had fully integrated LCs during their four years at UICCOM. We also plan to examine the impact of specific student variables such as gender, marital status, and class year on students’ perceptions of LCs.
According to our analysis, many students perceive positive outcomes, including fostering connection, excellence, leadership, learning, and service, related to the implementation of student-type LCs at UICCOM. LCs seem to increase student leadership development and engagement in the broader community. Not all students seem to participate in or benefit from LCs. Our evaluation also identified remaining challenges in fully implementing this type of model that will be helpful to medical school administrators considering or attempting the implementation of LCs. Most notable among these challenges is providing opportunities and support for the continued involvement of third- and fourth-year students in LCs as they participate in their clinical rotations. Further investigation is needed to determine how these potential benefits of LCs can be maximized and made more accessible to all students.
The authors would like to acknowledge the faculty, staff, collegiate administrators, and students who helped plan and implement the learning communities on which this research report is based.