Surprisingly, this study did not show a significant correlation between the educational climate in clinical departments and the leadership performance of the CRE. There could be various explanations for this finding including both internal and external validity threats.
Firstly, the scores on the educational climate were quite high with a mean score of 3.9 (SD 0.3) on a five-point Likert scale. Moreover, MSF scores on leadership performance were quite high with a mean value of 5.4 (SD 0.6) on a seven-point Likert scale. Both results might indicate an instrumentation bias. However, the scores on the educational climate in our study varied from 3.0 and 4.5. An educational climate score of 3.0 should be considered a low score, since there is a tendency to get positive scores in measurements of educational climate [25
]. Likewise, respondents in MSF procedures are known to give high scores on MSF [20
]. The scores on leadership performance ranged between 4.2 and 6.3. A score of 4.2 indicates a rather low leadership performance. The instruments therefore are both able to separate high performers from lower performing CREs and good from a less positive educational climate.
The response rate was moderate 52% (420/811) on the questionnaire on the educational climate and might pose a threat to the validity of these results. In average we got response from ten doctors from each department, which is enough to get a reliable measurement of the educational climate [27
Finally, we chose to calculate a total MSF score for all respondents. When measuring leadership performance through an MSF procedure you usually separate the respondents into subgroups according to their position in the organisation. Many studies have shown that you perceive the leaders' performance differently according to your position in the organisation (head of department, peer consultant and trainee) [22
]. However, in a previous study we have shown that there were only minor differences between the scores of various respondent groups on a MSF process in CREs in clinical departments [20
The rather high average score in educational climate and MSF scorings might indicate a positive selection bias. However, we excluded the departments where CREs had previously voluntarily signed up for a leadership course and most probably represented the most enthusiastic CREs in the region. Moreover, our study sample included 56 departments covering CREs and departments from a whole region in the country and comprising both university and non-university hospitals in addition to representing many specialties. Even with the lower representation of technical specialties in our study population compared to the background population we feel confident that the results reflect the population in general. Especially since the ratio between the cognitive and surgical specialty departments was the same in the study and the background population. The MSF instrument was developed in a way that only doctors could be invited as respondents. Extending the respondent groups to other staff groups in the department might be considered in future studies in order to achieve a more equal representation of specialties.
In summary, although we acknowledge limitations to our study these do not fully account for our findings. Therefore other explanations to the lack of relation between educational climate and CREs' leadership skills might be speculated, including organisational issues of PGME.
In one way PGME relates to a parallel organisation outside the organisation of hospitals and other health care organisations where PGME takes place [6
]. PGME is governed by outside bodies like a national boards of health (United Kingdom, Denmark)[15
], the Accreditations Councils (USA) [17
], specialist societies (Canada) [18
] or the union (Norway) [30
]. Contrary to this the CRE refers to the head of department in administrative matters. This unclear line of reference combined with an unclear task description may contribute to the CRE's low impact [19
]. The hospitals are run administratively through the heads of departments. This places the CRE in a position as middle manager primarily concerned with interpreting and implementing policies and programs from the educational bodies or places him as a low-level manager supposedly engaged in structuring, coordinating and facilitating work activities [24
]. In a previous study we have shown that the CRE is expected to manage a whole range of administrative duties [19
], among them ensuring that trainees are exposed to the clinical situations they are supposed to learn from. Structuring the learning opportunities and processes is very important in clerkship education [31
], and there is reason to believe that it might be even more important in PGME, where involvement, participation and interpersonal relations are so fundamental [33
]. Since stakeholders in PGME found that the CRE masters the administrative duties well [19
], we would have expected a relation between the organisation of work and management skills of the CRE. Finding no relation might reflect that the CRE have limited influence on the planning of daily work schedules. Both CREs and stakeholders have suggested the development of a specific leadership course for CREs to strengthen their position [19
]. However, if the CRE is in a weak position to influence the working organisation and educational climate these initiatives may be in vain [34
CREs might be fairly good leaders but acting in a system that makes it difficult to be perceived as a leader of education and creator of the educational culture. Additionally, the educational climate might be so mixed up in the work environment that maybe focus should be on the working culture instead of isolating the educational climate. This would involve asking other staff groups about their perception of the working culture in the clinical departments.
To further explore factors that influence the educational climate it might be relevant to focus on the leadership performance of the administrative heads of the clinical departments. In particular how the head of the department prioritises PGME and attends to the educational mission in the department. This might have significant influence on the CRE's possibility to excert leadership of education and fulfil expectations [24