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Association between learning environment and well-being of postgraduate residents in Kuwait

BMC Medical Education volume 25, Article number: 457 (2025) Cite this article

Abstract

Background

A positive educational environment in postgraduate medical education can immensely affect academic outcomes and lower residents’ chances of burnout. However, no studies were conducted in Kuwait to examine the educational environment and its association with residents’ well-being. This study aims to investigate the association between the current learning environment and the well-being of the trainees who are having rotations in hospitals in Kuwait.

Methods

A cross-sectional survey was distributed to all residents currently enrolled in postgraduate medical and dental educational programs. The survey included the Postgraduate Hospital Educational Environment Measure (PHEEM) and the World Health Organization (WHO)-5 Well-Being Index. Pearson’s correlation coefficient was used to measure the correlation between two quantitative variables, and linear regression analysis was used to assess factors associated with the well-being score.

Results

The analysis included 184 residents. The mean scores for role autonomy perception, teaching perception, and social support perception were 31.28 ± 11.33, 35.15 ± 13.72, and 23.14 ± 8.57, respectively, with a mean total PHEEM score of 89.58 ± 32.2. Residents’ well-being scores ranged from 5 to 25, with a mean of 12.26 ± 4.35. In regression analysis, increased role autonomy, teaching, and social support perception scores were associated with higher well-being. In a multivariable model, each one-unit increase in social support perception score was significantly associated with higher well-being by 0.16 (95%CI: 0.03 to 0.3, P = 0.014), which indicates the positive correlation between the social support elements in the educational environment and residents’ well-being. However, the study’s limitations, including small sample size and nonresponse bias, should be considered.

Conclusion

Assessing the hospital educational environment and residents’ well-being has provided vital insights into the strengths and areas needing improvement in postgraduate medical education. Addressing identified areas for improvement can significantly enhance the educational environment, thereby improving trainee satisfaction and well-being. Future studies should focus on confirming the results of this study, assessing proper interventions to improve the educational environment and focusing on social support interventions to improve residents’ well-being.

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Introduction

A learning environment is a group of factors describing the learner within an organisation [1]. It comprises three subdivisions: physical, emotional, and intellectual environment [1, 2]. The learning environment is paramount in providing effective [3] and high-quality [4, 5] medical education. A positive medical learning environment is linked to better learning outcomes, while a negative one is linked to less productivity [6]. A multicentre study in Japan investigated the association between the hospital environment and performance among residents’ physicians using the Postgraduate Hospital Educational Environment Measure (PHEEM) [6]. They found that residents who scored higher in their examinations had a higher score in the PHEEM. These results suggest an association between the learning environment and residents’ performance. At the same time, residents are known to be prone to burnout [7] and mental illness [8], which was linked to the learning environment [9, 10, 11, 12, 13, 14, 15, 16]. The PHEEM has been used internationally to assess the educational environments [17] and in Arab countries with similar healthcare and educational systems, such as Saudi Arabia [18, 19].

The Kuwait Institute for Medical Specializations (KIMS) plays a critical role in the future of healthcare in Kuwait by offering superior education and training for healthcare professionals. KIMS was established in 1983 and offers twenty-five residency training programs. However, the current state of the learning environment in KIMS programs still needs to be discovered. To date, no study has assessed the current state of the learning environment in KIMS training programs. Therefore, it is crucial to examine the learning environment more thoroughly to understand the current learning environment in KIMS training programs and to understand trainees’ preparedness for future independent practice, which is linked to the learning environment [20].

Despite being established in 1983, most studies conducted about KIMS were about the residents’ speciality choices [21], selection criteria in residency programs [22], the role of KIMS in developing the Kuwaiti health workforce [23], and the structures of residency programs [24]. Although some studies explored the mental health of residents in Kuwait [25, 26], to our knowledge, no studies have examined the well-being of residents or the education environment and its association with the postgraduate learning environment in Kuwait. The results of this study could shed light on the current state of well-being and the educational environment in Kuwait, providing a foundation for policy interventions and contributing to the literature for national, regional, and global comparisons. This study aims to assess the quality of the learning environment in KIMS training programs and investigate its association with the well-being of residents.

Materials and methods

Study setting and participants

This is a cross-sectional study. The study sample included all residents enrolled in KIMS postgraduate residency training programs who are attending their current rotations in a hospital. The only exclusion criterion was being enrolled in the fellowship training programs; this decision was based on the fact that fellows have different training environment and responsibilities that might affect the results of both educational environment and well-being. According to the latest data, 1008 residents were distributed between 25 residency training programs, and all were invited to participate in the study. The survey was distributed electronically through text/emails by the program directors or by the faculty staff of each faculty to all residents regardless of their training year, program, or training site. Data were collected between the 1st of June and the end of October 2023 with two-week reminders, done by resending the text/emails by the program directors or the faculty staff. A consent form was furnished to respondents for signing before starting the survey, as agreed by the ethics committee of the Ministry of Health.

Questionnaire

A survey was used to examine the educational environment in postgraduate programs and the well-being of residents attending hospital rotations. An Online survey was created using Google Forms and had three sections. The first section included socio-demographics, and the second section was the PHEEM, a validated instrument that measures the postgraduate educational environment [27] and has been used in several studies internationally and in the Middle East [1, 17, 19, 28]. Moreover, the PHEEM was shown to measure some aspects that can affect well-being, such as autonomy and social support [15]. The PHEEM scoring can be interpreted as an overall score and for each of the included subscales for autonomy, teaching, and social support. The PHEEM has 40 questions that are a 5-point Likert scale, which is scored as 4 for Strongly Agree, 3 for Agree, 2 for Uncertain, 1 for Disagree, and 0 for Strongly Disagree [27]. For questions (7, 8, 11, and 13), the scoring is 0 for Strongly Agree, 1 for Agree, 2 for Uncertain, 3 for Disagree and 4 for Strongly Disagree [27]. The questionnaire was adapted to the Kuwaiti context by adding another answer choice to the questions (not applicable), and those answers were excluded from the analysis.

The PHEEM total score can be interpreted as poor (0–40), plenty of problems (41–80), more positive than negative but room for improvement (81–120), and excellent (121–160) [27]. In terms of scoring of subscales, they are scored as follows: the perception of autonomy is scored as follows (0–14 very poor, 15–28 a negative view, 29–42 more positive perception, 43–56 excellent perception of one’s job); perceptions of teaching (0–15 very poor quality,16–30 in need of some retraining, 31–45 moving in the right direction, 46–60 model teachers); Perceptions of social support (0–11 non-existent); (12–22 not a pleasant place), (23–33 more pros than cons), (34–44 a good supportive environment) [27]. The third section was the WHO-5 Well-Being Index [29], which is a validated instrument to examine psychological and mental well-being [30, 31] and was used to assess higher education students’ well-being [32].

Data analysis

Data were uploaded to SPSS (IBM Co., Armonk, NY, USA) software. Numerical data were presented as the mean and standard deviation (SD), analysed between the two groups by an independent samples t-test, and across more than two groups by a one-way ANOVA test after testing for normality using the Shapiro-Wilk test. Categorical data were presented as the frequency and percentage. Pearson’s correlation coefficient was calculated to estimate the degree of correlation between two quantitative variables. The association between PHEEM score subdomains and WHO Well-being score was done using multiple linear regression while controlling for gender, year of residency, age, marital status, and nationality. A two-tailed P value < 0.05 was considered statistically significant. Using an electronic survey resulted in no missing data from the filled surveys.

Results

Out of the 1008 distributed surveys, 258 filled out the survey, 5 refused participation, and 69 were not in a hospital rotation. A total of 184 residents (96 males and 88 females) enrolled in KIMS residency programs and having their current rotations in hospitals were included in our survey (response rate 18.3%). First, second, third, fourth and fifth-year residents represented 19.57%, 25%, 23.91%, 18.48% and 13.04%, respectively, with a mean age of 30.26 ± 2.84 years (range between 26 and 41 years). Over half of the population (58.7%) were married. Most responses were from Kuwaiti residents (91.85%). Internal Medicine was the predominant training program (19.57%) (Table 1, Supplementary material).

Regarding the hospital educational environment, the highest levels of agreement were that the residents had a good collaboration with other doctors in their year group (with a total agreement rate of 79.89%), clinical teachers were accessible (76.63%), they were able to participate actively in educational events (76.09%), and clinical teachers encouraged them to be independent learners (75.54%). Conversely, the statements with the lowest approval were that there was sex discrimination in that rotation (with a total disagreement rate of 66.3%), there was racism in that rotation (65.76%), and they were bleeped/called inappropriately (63.04%) (Table 2, Supplementary material). Overall, the mean role autonomy perception score was 31.28 ± 11.33 (range between 0 and 56), the teaching perception score was 35.15 ± 13.72 (range between 0 and 60), and the social support perception score was 23.14 ± 8.57 (range between 0 and 44), with a mean total PHEEM score of 89.58 ± 32.2 (range between 0 and 160). Regarding the residents’ well-being, the total score ranged from 5 to 25 with a mean of 12.26 ± 4.35 (62.5% of residents manifested poor well-being with ≤ 50% of total score and 37.5% manifested good well-being with > 50% of total score), (Table 3, Supplementary material).

No statistically significant association existed between residents’ socio-demographics and well-being scores (Table 4, Supplementary material). According to Pearson’s correlation analysis, the well-being score of residents was significantly positively correlated with PHEEM sub-scales represented by role autonomy perception (r = 0.514, P < 0.001), teaching perception (r = 0.517, P < 0.001) and social support perception (r = 0.552, P < 0.001), in addition to total score (r = 0.548, P < 0.001), Figs. 1, 2, 3 and 4. This significant correlation indicated that as the postgraduate educational environment in hospitals is better, the degree of well-being of residents is higher. A subgroup analysis examining the correlation between PHEEM and WHO well-being scores by gender revealed similar results for both males and females. In terms of year of residence, the correlation coefficient was not statistically significant and considerably lower for fifth-year residents (Figs. 5 and 6; Table 6 in Supplementary material).

Fig. 1
figure 1

Scatter plot demonstrating the correlation between the role autonomy perception score of residents and their well-being score

The figure demonstrates a positive correlation between role autonomy perception and residents’ well-being

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Fig. 2
figure 2

Scatter plot demonstrating the correlation between the teaching perception score of residents and their well-being score

The figure demonstrates a positive correlation between teaching perception and residents’ well-being

Full size image
Fig. 3
figure 3

Scatter plot demonstrating the correlation between the social support perception score of residents and their well-being score

The figure demonstrates a positive correlation between social support perception and residents’ well-being

Full size image
Fig. 4
figure 4

Scatter plot demonstrating the correlation between the total PHEEM score of residents and their well-being score

The figure demonstrates a positive correlation between the total PHEEM and residents’ well-being

Full size image
Fig. 5
figure 5

Scatter plot demonstrating the correlation between the total PHEEM score of residents and their well-being score categorized by gender

The figure illustrates a positive correlation between the total PHEEM and residents’ well-being, showing no impact of gender

Full size image
Fig. 6
figure 6

Scatter plot demonstrating the correlation between the total PHEEM score of residents and their well-being score categorized by year of residency

The figure illustrates a correlation between total PHEEM and residents’ well-being across all years of residency; however, no correlation was observed in the fifth year

Full size image

In univariate regression analysis, PHEEM of residents was the only independent predictor of their well-being as each 1 unit increase in the scores of role autonomy, teaching and social support perceptions resulted in increasing well-being scores respectively by 0.2 (95%CI: 0.15 to 0.25), 0.16 (95%CI: 0.12 to 0.2) and 0.28 (95%CI: 0.22 to 0.34) with P values < 0.001. After adjustment for all factors in a multivariable model, the social support perception score of residents was significantly associated with their well-being as each 1 unit increase in the score resulted in increasing well-being score by 0.16 (95%CI: 0.03 to 0.3, P = 0.014), (Table 5, Supplementary material). This result indicates that more social support increases the degree of well-being of residents.

Discussion

The assessment of the hospital educational environment, as evaluated by residents, provides crucial insights into the strengths and areas needing improvement in postgraduate medical education. This study utilised the PHEEM and the WHO-5 Well-Being Index to quantify various aspects of the residents’ experiences and well-being.

Our study’s findings align closely with the broader literature on using the PHEEM in evaluating educational environments. Findings from the present study showed high agreement on good collaboration with peers and accessibility of clinical teachers, in addition to high levels of satisfaction with teaching, role autonomy, and social support. This was consistent with other studies [4, 33, 34]. Similar to the present study, Kouhsoltani, and Ghafarir [33] and Algaidi S. et al. [4] identified the need for improvements in the clarity of clinical protocols and physical facilities, reflecting common challenges across different educational contexts​.

The systematic review by Chan et al. [17] analysed data from 30 studies across 14 countries, demonstrating significant differences in PHEEM scores based on training levels, disciplines, and clinical sites. Consistent with our results, the review found strong correlations between higher PHEEM scores, better In-Training Exam performance, and lower levels of burnout among trainees. This underscores the importance of a positive educational environment in enhancing trainee performance and well-being​. Similar to the present study, other studies reported significant correlations between PHEEM scores and resident well-being, with social support as a key predictor [16, 35]. This result is supported by studies that demonstrated the positive effect of social support on residents’ well-being [36], lower levels of burnout, and improved satisfaction levels [37]. Furthermore, social support has been shown to improve residents’ mental health by affecting depression and anxiety symptoms [38]. This reinforces the critical role of a supportive educational environment in promoting mental health and professional satisfaction among trainees​.

Regarding the residents’ well-being, the present study showed that the total WHO-5 Well-Being Index scores ranged from 5 to 25, with a mean of 12.26 ± 4.35 (Table 3, Supplementary material). Notably, 62.5% of residents manifested poor well-being, scoring ≤ 50% of the total score (Table 3, Supplementary material). A significant portion of residents also reported low levels of feeling active and vigorous, waking up fresh and rested, and finding their daily life interesting, with the majority experiencing these feelings less than half of the time or not at all. This indicates a considerably high prevalence of poor well-being among residents. These results were similar to other studies that used the WHO-5 Well-Being Index to measure the well-being of residents [39, 40]. However, the low response rate might explain the insignificant association between well-being and demographic variables.

These results could be explained by the fact that well-being among residents can be significantly affected by factors such as work hours, sleep deprivation, and the stressful nature of medical training [15]. The baseline well-being levels in the present study appear to be lower than those typically reported, which suggests that our residents may be experiencing higher levels of stress and burnout. This emphasises the urgent need for targeted interventions to enhance their well-being and support their mental health.

On the other hand, other studies in the literature showed that well-being in the Kuwaiti culture can be linked to other factors, such as self-esteem, optimism, and religiosity [41]. Residents’ job satisfaction could also affect their well-being, especially since it is linked to mental health [42]. Cultural factors in Kuwait may significantly influence residents’ well-being and their interpretation of PHEEM scores. Strong familial ties and societal expectations can shape stress levels, job satisfaction, and perceptions of autonomy. Religious beliefs and practices, such as prayer and community support, may serve as coping mechanisms, affecting mental health resilience. Additionally, hierarchical workplace structures in Kuwaiti healthcare settings might impact how residents perceive supervision and independence. Social norms around expressing dissatisfaction may also lead to underreporting of workplace challenges. These factors highlight the need for culturally tailored interventions to improve well-being and accurately interpret educational environment assessments.

Several recommended interventions, like mindfulness training, support groups, and changes in working hours, can improve well-being [15]. For instance, tailored programs that focus on residents’ mental and physical health and address their well-being holistically can be implemented [43]. Furthermore, multidimensional programs that address issues, such as mentorship, psychological counselling and physical activities, can also be adopted [44].

Limitations

The study’s limitations arise from its small sample size and low response rate, factors that may compromise the generalizability of the findings. Another limitation is the possibility of nonresponse bias, especially with the study’s low response rate, which occurred despite the efforts to encourage participation through ten reminders over five months, which can affect the significance of the results. Furthermore, the study’s cross-sectional design poses challenges in establishing causal relationships between variables. While it can uncover associations, the temporal sequence of events remains elusive, precluding definitive conclusions about cause and effect. Thus, interpreting the results requires caution, as they may not directly indicate causal relationships. Besides the factors mentioned earlier, the cultural and health systems in differences Kuwait might affect the generalisability of the results.

Implications to practice

The findings from our study and corroborating literature highlight several practical implications for improving the educational environment in clinical training settings. Firstly, enhancing the accessibility of clinical teachers and fostering good peer collaboration can significantly improve trainee satisfaction and learning outcomes. Ensuring that clinical protocols are clear and physical facilities are adequate is also essential for a conducive learning environment. Moreover, institutions may prioritise the development of structured support systems to enhance social support and role autonomy, as these factors are strongly correlated with trainee well-being. Role autonomy can be enhanced by implementing structured competency-based training programs that allow for progressive responsibility. This includes clear milestone-based evaluations and supervised independent decision-making opportunities. Additionally, the establishment of resident-led committees to participate in policy-making and educational planning can empower residents and foster a sense of ownership over their training experience. On the other hand, teaching quality could be improved by introducing faculty development programs that include training in modern pedagogical techniques, feedback delivery, and learner-centred teaching methods. Regular peer and learner feedback mechanisms should also be established to ensure continuous improvement in teaching quality. Regular use of PHEEM for diagnostic purposes can help institutions identify strengths and areas needing improvement, facilitating continuous quality enhancement in postgraduate medical education.

Future research

Future research should focus on longitudinal studies in the form of cohort studies to observe changes in educational environments over time, providing deeper insights into the long-term impact of interventions to improve these environments. Qualitative studies can be done to explore in depth the causes of low levels of well-being and its association with the educational environment.

Exploring other correlates of PHEEM, such as specific training levels, disciplines, and clinical sites, can provide a more nuanced understanding of how different factors influence educational outcomes. Moreover, future studies could aim to investigate the direct impact of improved educational environments on specific outcomes like exam performance, burnout levels, and overall professional development. Furthermore, quasi-experimental studies can be conducted to study and evaluate the effectiveness of interventions to improve residents’ well-being.

Conclusion

The assessment of the hospital educational environment through the PHEEM and WHO-5 index has provided vital insights into both the strengths and areas needing improvement in postgraduate medical education. This study uniquely contributes to the field by offering a contextualised evaluation of the learning environment in Kuwait, highlighting cultural and systemic factors influencing trainee experiences. Our findings reinforce the importance of a supportive educational environment in enhancing trainee performance and well-being. The notably low well-being scores underscore an urgent need for targeted interventions, including structured mentorship, workload adjustments, and mental health support, to foster a more sustainable and enriching training experience. Addressing identified areas for improvement can significantly enhance the educational environment, thereby improving trainee satisfaction and well-being.

Data availability

Data available within the article or its supplementary materials.

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Acknowledgements

The authors thank all residents who participated in this study and Dr Abdullah Rajab and Dr Rawan S Hashem for their help in conducting the research.

Funding

No funding was received for this research.

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Authors and Affiliations

  1. Ministry of Health, Kuwait City, Kuwait

    Abdulaziz Alhenaidi, Basema Alqallaf, Sultan Alsalahi, Mohamed Elsherif & Hisham Kelendar

  2. Pharmacy Practice Department, College of Pharmacy, Kuwait University, Kuwait City, Kuwait

    Asmaa Al-Haqan

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  1. Abdulaziz Alhenaidi
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Contributions

AA: Study Idea, research protocol, data collection, and writing the manuscript. SA: Writing the manuscript. BA: Study Idea, research protocol and data collection. AH: Writing the manuscript. ME: Statistical analysis and writing of the manuscript. HK: Study Idea, research protocol and data collection.

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Correspondence to Abdulaziz Alhenaidi.

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Ethics approval and consent to participate

The Kuwait Ministry of Health scientific research ethics committee approved this research (Approval: 2022/2106) on October 5, 2022. A consent form was furnished to respondents for review and signature before starting the survey.

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The authors declare no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

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Alhenaidi, A., Alqallaf, B., Alsalahi, S. et al. Association between learning environment and well-being of postgraduate residents in Kuwait. BMC Med Educ 25, 457 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12909-025-07030-z

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Keywords

BMC Medical Education

ISSN: 1472-6920

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