Supervised learning events in the foundation programme: a UK-wide narrative interview study

If we assess, will they learn? Students' perspectives on the complexities of assessment-for-learning

Introduction

Assessment can positively influence learning, however designing effective assessment-for-learning interventions has proved challenging. We implemented a mandatory assessment-for-learning system comprising a workplace-based assessment of non-medical expert competencies and a progress test in undergraduate medical education and evaluated its impact.

Methods

We conducted semi-structured interviews with year-3 and 4 medical students at McGill University to explore how the assessment system had influenced their learning in year 3. We conducted theory-informed thematic analysis of the data.

Results

Eleven students participated, revealing that the assessment influenced learning through several mechanisms. Some required little student engagement (i.e., feed-up, test-enhanced learning, looking things up after an exam). Others required substantial engagement (e.g., studying for tests, selecting raters for quality feedback, using feedback). Student engagement was moderated by the perceived credibility of the system and of the costs and benefits of engagement. Credibility was shaped by students' goals-in-context: becoming a good doctor, contributing to the healthcare team, succeeding in assessments.

Discussion

Our assessment system failed to engage students enough to leverage its full potential. We discuss the inherent flaws and external factors that hindered student engagement. Assessment designers should leverage easy-to-control mechanisms to support assessment-for-learning and anticipate significant collaborative work to modify learning cultures.

Factors that may improve paediatric workplace-based assessments: an exploratory study

OBJECTIVES

To establish if paediatric trainees are satisfied with the current workplace-based assessment (WBA) process. To identify factors that contribute both positively and negatively to the educational experience during WBAs. To find out if trainees and their supervisors experience any challenges conducting WBAs. To establish potential ways to improve future assessments.

DESIGN

Qualitative semistructured interviews.

SETTING

Participants included fifteen trainees (ST1-8) in general paediatric and subspecialty posts and four consultants or equivalent across five hospital sites in the Thames Valley Deanery. All participants had regular exposure to WBAs.

INTERVENTIONS

Interviews were undertaken between June 2020 and January 2021 via video link. Data collection and analysis were conducted iteratively using constant comparison until theoretical sufficiency was achieved.

MAIN OUTCOME MEASURE

Using Constructivist Grounded Theory, a theoretical framework, grounded in the data, was developed that depicted the core elements that should be present to optimise WBAs.

RESULTS

A number of key components were reported to affect the educational value of WBAs. A positive departmental culture towards education and training is essential. Chosen cases should be challenging, and direct observation or in-depth discussion, depending on the assessment type, is fundamental. Timely constructive feedback and immediate completion of the assessment form are also imperative.

CONCLUSION

Some trainees experienced WBAs where these key components aligned, but many did not, and this negatively affected their learning. Three main challenges or future targets for further improvements include increasing time, improving training and optimising technology.

Services Available at United States Addiction Treatment Facilities That Offer Medications versus Behavioral Treatment Only: A Cross-Sectional, Observational Analysis

Purpose

Substance use disorders (SUDs) are widespread and cause significant morbidity and mortality, yet most people in the United States with a SUD do not receive treatment. Recommendations call for widespread use of pharmacotherapy, including medications for opioid use disorder (MOUD). However, many facilities do not offer a full array of medication treatments. This study aims to characterize programs that do and do not offer pharmacotherapy as part of addiction treatment services. We hypothesized that the availability of pharmacotherapy would predict the existence of other recommended components of treatment.

Patients and Methods

We analyzed characteristics regarding treatment facilities (n = 15,782) recorded by the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) to determine how many SUD treatment facilities offer any pharmacotherapy. We compared facilities that offer any pharmacotherapy to facilities that offer none.

Results

We found that 65% of SUD treatment facilities that responded to the N-SSATS survey provided at least one pharmacotherapy, while 35% of SUD treatment facilities did not. The facilities that provided at least one pharmacotherapy offered, on average, 6 additional treatment options (Cohen’s d = 0.87; 95% CI: 0.84–0.91). Psychiatric medications were the most commonly available pharmacotherapy, followed by buprenorphine/naloxone and naltrexone.

Conclusion

These results support that pharmacotherapy availability, such as MOUD, at SUD treatment facilities is associated with an increased number of recommended treatment components. Since MOUD has been shown elsewhere to reduce mortality for people with OUD, it should be universally available at SUD treatment facilities. Further efforts are needed to make pharmacotherapy more widely available.

The usefulness of work-based assessments in higher surgical training: A systematic review

BACKGROUND

Work-based assessments including procedure based assessments, case based discussions, clinical evaluation exercises and direct observation of procedural skills are used in Higher Surgical Training Program. This systematic review aims to investigate the trainer and trainee's perception of the usefulness of workplace based assessments in Higher Surgical Training Programme.

MATERIALS AND METHODS

Embase, MEDLINE and PubMed databases were searched for relevant studies published up to Jan 15, 2021. The following search terms were used: procedure based assessments, case based discussions, clinical evaluation exercises, direct observation of procedural skills, Higher Surgical Training Program (with and without their abbreviations), surgical training, formative assessment. Usefulness was analysed according to van der Vleuten's utility formula, which is the product of educational impact, validity, reliability, acceptability, cost-effectiveness and feasibility.

RESULTS

23 studies were included; Six on procedure based assessments, two on case based discussions, one on mini clinical evaluation exercises, three on direct observation of procedural skills and eleven on multiple methods. Overall, procedure based assessments had positive Kirkpatrick level 1 or 2 impact were valid, reliable and acceptable. Mini clinical evaluation exercises showed positive Kirkpatrick level 1 satisfaction in trainees and trainers and were feasible. Case based discussions were shown to have both positive and negative Kirkpatrick levels 1 and 2 impact and were rated valid and reliable. Direct observation of procedural skills were valid with favourable Kirkpatrick level 1 impact with more usage and modification of the forms. Multiple methods as used in the intercollegiate surgical curriculum programme portfolio was found to be less encouraging in achieving positive higher level of educational impact. The barriers included lack of time, lack of faculty development and lack of engagement.

CONCLUSION

It is important that work-based assessments are used properly, so that trainees get the maximum benefit from them. None of the studies included in our systematic review demonstrated an impact on behaviour or society (Kirkpatrick level 3 and 4), towards which future research should be directed to.

Factors relating to working hours restriction that have impacted the professional identity of trainees in the last decade

Ever-developing changes to the working hours of junior doctors by the European Working Time Directive, the junior doctor contract of 2019 and most recently the COVID-19 pandemic have impacted the professional identity of doctors. There has been little investigation into its influence on the multifaceted aspects of postgraduate medical training, which feeds into how trainees consider themselves professionally and the concept of professional identity or 'being a doctor'. A review of the medical, socio-political and educational literature reveals that the impact on the professional identity development of trainees is influenced by several perspectives from the trainee, trainer and the public. Gross reduction in working hours has no doubt decreased the raw volume of clinical experiences. However, to counteract this, smarter learning processes have evolved, including narrative reflection, supervised learning events, and a greater awareness of coaching and training among trainers.

Changes in UK medical trainees' perceptions of workplace-based assessments across 10 years: results from two cross-sectional studies

OBJECTIVES

Workplace-based assessments (WPBAs) have become embedded in the training and assessment of UK medical trainees since the onset of the 21st century. When first introduced WPBA required a significant adjustment in both trainees' and educators' training behaviour, and was met with scepticism in some quarters. In this study, we aimed to evaluate how trainees' perceptions of WPBAs have evolved over a 10-year period, as experience with them has increased.

DESIGN

Two online questionnaires were constructed and distributed to UK trainees. The first was distributed in 2008, the second in 2018. Questions related to trainees' perception of WPBAs as a learning process and as a reflection of their competence.

SETTING AND PARTICIPANTS

All UK medical trainees were eligible to respond. In 2008, 482 trainees from 96 hospitals completed the questionnaire. In 2018, 356 trainees from 103 hospitals completed the questionnaire.

MAIN OUTCOME MEASURES

Data were analysed both quantitatively and qualitatively. A comparison between the numbers of each WPBA modality completed in 2008 and 2018 was assessed using chi-squared test. Comparisons of Likert scale values between 2008 and 2018 were assessed using unpaired t-test. Thematic analysis was carried out on free-text answers.

RESULTS

The number of forms completed per participant increased significantly from 2008 to 2018. In 2008, forms were most commonly completed immediately after a learning observation (34%). In 2018, forms were most commonly completed between 1 week and 1 month after observation (58%). In 2018, significantly fewer WPBAs were followed by an educational/beneficial discussion in comparison to 2008 data. The most common free-text theme in the 2008 data set was 'supervisor issues' whereas in 2018 the most commonly noted theme was 'limited educational benefit'.

CONCLUSIONS

Our study suggests trainees' perspectives of WPBAs have not changed in the 10 years since implementation. Trainees do not perceive WPBA as an accurate reflection of their competency but instead as a 'tick-box' bureaucratic exercise to enable career progression. Development of educator training and trainer and trainee job-planning is required to ensure that WPBAs are genuinely educational activities that offer an accurate reflection of trainees' medical competence.

An evaluation of civilian and military dental foundation training

Background and aim There is little available material relating to the quality of continuing professional development for dental professionals and no studies to investigate whether dental foundation training (DFT) is meeting its aims and objectives. This study aimed to evaluate the components of DFT within the military and Oxford deaneries from the perspective of the educational supervisors (ESs) and foundation trainees (FTs).Method Questionnaires were sent to all 124 FTs and ESs involved in DFT in the Oxfordshire and military deaneries between 2012 to 2015. Following thematic analysis of the free text from the questionnaires, an interview guide was produced which mapped the main themes for a series of semi-structured interviews.Results Sixty-six questionnaires were returned (53% response rate) from 18 military and 3 Oxford ESs (21), and 30 military and 15 Oxford FTs (45). Eighteen interviews were carried out (6 ES/12 FT). The questionnaires highlighted the educational benefit of workplace-based assessments, joint clinical sessions and the importance of an ES as a positive role model, while the interviews highlighted the facilitative benefit of effective supervision, timely feedback, practice-wide teamwork, appropriate assessments and formal/informal peer review.Conclusions This study demonstrates the benefit of creating an optimal learning environment for DFT within the context of professional and ethical organisational support and appropriate clinical resources. ESs have a critical part to play as professional and clinical role models, and in ensuring an accountable and formal educational delivery, targeted learning goals, flexible delivery and timely feedback.

Why health professions education needs functional linguistics: the power of 'stealth words'

CONTEXT

Language is one of the primary modalities for teaching and learning in the health professions in contexts ranging from the more formal teaching relationships of medical school to the guided practice of trainees through continuing education and the deliberate practice of lifelong learning. Yet linguistic analysis, with the possible exception of discourse analysis, has not become a core methodological tool in the field of health professions education (HPE). The purpose of this paper is to argue for the more widespread adoption of one particular approach to linguistics, one that examines less of what learners and instructors say and looks more at how they say it: functional linguistics.

FUNCTIONAL LINGUISTICS

THE POWER OF 'STEALTH WORDS': This approach theorises and structures the functions of language, regularly focusing attention on 'stealth words' such as I, but and was. Drawing on a rich body of literature in linguistics, psychology, the learning sciences and some early work in HPE, we demonstrate how functional linguistic tools can be applied to better understand learners' and instructors' beliefs, reasoning processes, values and emotions.

FUNCTIONAL LINGUISTICS AND REFLECTION

AN APPLICATION OF STEALTH WORDS: A brief qualitative analysis of one tool - analysis of the generic use of 'you' to mean 'one' or 'anyone' - demonstrates how functional linguistics can offer insight into physicians' bids for credibility and alignment as they think aloud about their clinical reasoning.

FUNCTIONAL LINGUISTICS AND HPE

FUTURE DIRECTIONS: Finally, we offer suggestions for how functional linguistic tools might address questions and gaps in four active research areas in HPE: reflection; emotion and reasoning; learning in simulated contexts, and self-regulated learning.

CONCLUSIONS

We argue that the words used by learners, instructors and practitioners in the health professions as they move through undergraduate and graduate training into practice can offer clues that will help researchers, instructors and colleagues to better support them.

Self-regulated learning lens on trainee perceptions of the mini-CEX: a qualitative study

OBJECTIVES

The formative aspect of the mini-clinical evaluation exercise (mini-CEX) in postgraduate medical workplace-based assessment is intended to afford opportunities for active learning. Yet, there is little understanding of the perceived relationship between the mini-CEX and how trainees self-regulate their learning. Our objective was to explore trainees' perceptions of their mini-CEX experiences from a learning perspective, using Zimmerman's self-regulated learning theoretical framework as an interpretive lens.

DESIGN

Qualitative, using semi-structured interviews conducted in 2017. The interviews were analysed thematically.

SETTING

Geriatric medicine training.

PARTICIPANTS

Purposive sampling was employed to recruit geriatric medicine trainees in Melbourne, Australia. Twelve advanced trainees participated in the interviews.

RESULTS

Four themes were found with a cyclical inter-relationship between three of these themes: namely, goal setting, task translation and perceived outcome. These themes reflect the phases of the self-regulated learning framework. Each phase was influenced by the fourth theme, supervisor co-regulation. Goal setting had motivational properties that had significant impact on the later phases of the cycle. A 'tick box' goal aligned with an opportunistic approach and poorer perceived educational outcomes. Participants reported that external feedback following assessment was critical for their self-evaluation, affective responses and perceived outcomes.

CONCLUSIONS

Trainees perceived the performance of a mini-CEX as a complex, inter-related cyclical process, influenced at all stages by the supervisor. Based on our trainee perspectives of the mini-CEX, we conclude that supervisor engagement is essential to support trainees to individually regulate their learning in the clinical environment.

Assessing professional competence: a critical review of the Annual Review of Competence Progression

The Annual Review of Competence Progression is used to determine whether trainee doctors in the United Kingdom are safe and competent to progress to the next training stage. In this article we provide evidence to inform recommendations to enhance the validity of the summative and formative elements of the Annual Review of Competency Progression. The work was commissioned as part of a Health Education England review. We systematic searched the peer reviewed and grey literature, synthesising findings with information from national, local and specialty-specific Annual Review of Competence Progression guidance, critically evaluating the findings in the context of literature on assessing competence in medical education. National guidance lacked detail resulting in variability across locations and specialties, threatening validity and reliability. Trainees and trainers were concerned that the Annual Review of Competence Progression only reliably identifies the most poorly performing trainees. Feedback is not routinely provided, which can leave those with performance difficulties unsupported and high performers demotivated. Variability in the provision and quality of feedback can negatively affect learning. The Annual Review of Competence Progression functions as a high-stakes assessment, likely to have a significant impact on patient care. It should be subject to the same rigorous evaluation as other high-stakes assessments; there should be consistency in procedures across locations, specialties and grades; and all trainees should receive high-quality feedback.

Understanding students' and clinicians' experiences of informal interprofessional workplace learning: an Australian qualitative study

OBJECTIVES

While postgraduate studies have begun to shed light on informal interprofessional workplace learning, studies with preregistration learners have typically focused on formal and structured work-based learning. The current study investigated preregistration students' informal interprofessional workplace learning by exploring students' and clinicians' experiences of interprofessional student-clinician (IPSC) interactions.

DESIGN

A qualitative interview study using narrative techniques was conducted.

SETTING

Student placements across multiple clinical sites in Victoria, Australia.

PARTICIPANTS

Through maximum variation sampling, 61 participants (38 students and 23 clinicians) were recruited from six professions (medicine, midwifery, nursing, occupational therapy, paramedicine and physiotherapy).

METHODS

We conducted 12 group and 10 individual semistructured interviews. Themes were identified through framework analysis, and the similarities and differences in subthemes by participant group were interrogated.

RESULTS

Six themes relating to four research questions were identified: (1) conceptualisations of IPSC interactions; (2) context for interaction experiences; (3) the nature of interaction experiences; (4) factors contributing to positive or negative interactions; (5) positive or negative consequences of interactions and (6) suggested improvements for IPSC interactions. Seven noteworthy differences in subthemes between students and clinicians and across the professions were identified.

CONCLUSIONS

Despite the results largely supporting previous postgraduate research, the findings illustrate greater breadth and depth of understandings, experiences and suggestions for preregistration education. Educators and students are encouraged to seek opportunities for informal interprofessional learning afforded by the workplace.

Exploring trainer and trainee emotional talk in narratives about workplace-based feedback processes

Emotion characterises learners' feedback experiences. While the failure-to-fail literature suggests that emotion may be important, little is known about the role of emotion for educators. Secondary analyses were therefore conducted on data exploring 110 trainers' and trainees' feedback experiences. Group and individual narrative interviews were conducted across three UK sites. We analysed 333 narratives for emotional talk using textual analysis: Linguistic Inquiry and Word Count. Furthermore, thematic framework analysis was conducted on the trainer narratives to explore aspects of feedback processes that are emotional. An additional in-depth little 'd' discourse analysis was conducted on selected trainer narratives to enable us to explore the complex relationship between the whats (reported events) and the hows (emotional talk). Trainer narratives did not differ significantly in positive or negative emotional talk from trainee narratives. By exploring the interplay of the whats and the hows, several aspects of feedback processes were identified as potentially emotional for trainers including trainers being concerned about upsetting learners and worried about patient safety. This was illustrated through numerous linguistic devices to establish emotional tone such as metaphoric talk and laughter. These findings suggest that feedback processes can be emotional for trainers. It highlights the need to better understand the 'filter' of emotion for trainers but also to better understand how emotion plays a role in feedback as a complex social process.

Psychiatry in the Foundation Programme: An overview for supervisors

Health Education England's 2014 reportBroadening the Foundation Programmehas led to a rapid increase in the number of psychiatry placements for foundation doctors. This will have implications for existing psychiatrists in that they will start to teach, train and supervise foundation doctors. This article outlines how to develop high-quality foundation posts and how to support doctors in meeting the foundation curriculum competencies, which include experience of working in multidisciplinary teams and developing communication skills. The knowledge and skills gained in psychiatry placements will be valuable to all doctors, no matter what their future career intentions.

Learning Objectives

• Describe the recent changes to the Foundation Programme in psychiatry and how they will affect supervisors

• Learn how high-quality placements for foundation doctors can be developed

• Recognise how foundation doctors can be supported to achieve the generic and mental health-specific competencies of the foundation curriculum in psychiatry placements

The validity of the Annual Review of Competence Progression: a qualitative interview study of the perceptions of junior doctors and their trainers

Objective To investigate trainee doctors' and trainers' perceptions of the validity of the Annual Review of Competence Progression (ARCP) using Messick's conceptualisation of construct validity. Design Qualitative semi-structured focus groups and interviews with trainees and trainers. Setting Postgraduate medical training in London, Kent Surrey and Sussex, Yorkshire and Humber, and Wales in November/December 2015. Part of a larger study about the fairness of postgraduate medical training. Participants Ninety-six trainees and 41 trainers, comprising UK and international medical graduates from Foundation, General Practice, Medicine, Obstetrics and Gynaecology, Psychiatry, Radiology, and Surgery, at all levels of training. Main outcome measures Trainee and trainer perceptions of the validity of the ARCP as an assessment tool. Results Participants recognised the need for assessment, but were generally dissatisfied with ARCPs, especially UK graduate trainees. Participants criticised the perceived tick-box nature of ARCPs as measuring clerical rather than clinical ability, and which they found detrimental to learning. Trainees described being able to populate their e-portfolios with just positive feedback; they also experienced difficulty getting assessments signed off by supervisors. ARCPs were perceived as poor at identifying struggling trainees and/or as discouraging excellence by focussing on minimal competency. Positive experiences of ARCPs arose when trainees could discuss their progress with interested supervisors. Conclusions Trainee and trainer criticisms of ARCPs can be conceptualised as evidence that ARCPs lack validity as an assessment tool. Ongoing reforms to workplace-based assessments could address negative perceptions of the 'tick-box' elements, encourage constructive input from seniors and allow trainees to demonstrate excellence as well as minimal competency, while keeping patients safe.

A BEME (Best Evidence in Medical Education) review of the use of workplace-based assessment in identifying and remediating underperformance among postgraduate medical trainees: BEME Guide No. 43

INTRODUCTION

The extent to which workplace-based assessment (WBA) can be used as a facilitator of change among trainee doctors has not been established; this is particularly important in the case of underperforming trainees. The aim of this review is to examine the use of WBA in identifying and remediating performance among this cohort.

METHODS

Following publication of a review protocol a comprehensive search of eight databases took place to identify relevant articles published prior to November 2015. All screening, data extraction and analysis procedures were performed in duplicate or with quality checks and necessary consensus methods throughout. Given the study-level heterogeneity, a descriptive synthesis approach informed the study analysis.

RESULTS

Twenty studies met the inclusion criteria. The use of WBA within the context of remediation is not supported within the existing literature. The identification of underperformance is not supported by the use of stand-alone, single-assessor WBA events although specific areas of underperformance may be identified. Multisource feedback (MSF) tools may facilitate identification of underperformance.

CONCLUSION

The extent to which WBA can be used to detect and manage underperformance in postgraduate trainees is unclear although evidence to date suggests that multirater assessments (i.e. MSF) may be of more use than single-rater judgments (e.g. mini-clinical evaluation exercise).

'I wish someone watched me interview:' medical student insight into observation and feedback as a method for teaching communication skills during the clinical years

BACKGROUND

Experts suggest observation and feedback is a useful tool for teaching and evaluating medical student communication skills during the clinical years. Failing to do this effectively risks contributing to deterioration of students' communication skills during the very educational period in which they are most important. While educators have been queried about their thoughts on this issue, little is known about what this process is like for learners and if they feel they get educational value from being observed. This study explored student perspectives regarding their experiences with clinical observation and feedback on communication skills.

METHODS

A total of 125 senior medical students at a U.S. medical school were interviewed about their experiences with observation and feedback. Thematic analysis of interview data identified common themes among student responses.

RESULTS

The majority of students reported rarely being observed interviewing, and they reported receiving feedback even less frequently. Students valued having communication skills observed and became more comfortable with observation the more it occurred. Student-identified challenges included supervisor time constraints and grading based on observation. Most feedback focused on information gathering and was commonly delayed until well after the observed encounter.

CONCLUSIONS

Eliciting students' perspectives on the effect of observation and feedback on the development of their communication skills is a unique way to look at this topic, and brings to light many student-identified obstacles and opportunities to maximize the educational value of observation and feedback for teaching communication, including increasing the number of observations, disassociating observation from numerically scored evaluation, training faculty to give meaningful feedback, and timing the observation/feedback earlier in clerkships.

Surgical learning activities for house officers: do they improve the surgical experience?

OBJECTIVE

To ascertain whether house officers (HOs) attain a more satisfactory surgical rotation experience when they perform basic surgical learning activities. We also sought to establish how many and which learning activities HOs achieve and the effect on their surgical experience.

METHODOLOGY

A questionnaire listing 20 learning activities and questions regarding satisfaction with an overall experience was disseminated to HOs in the UK and Ireland who had completed ≥3 months of surgical rotations. Satisfaction with surgical experience was dichotomised in order to perform logistic regression using R Studio software v0.98.

RESULTS

The survey was completed by 150 respondents, with 26 % completing at least 10 basic surgical learning activities during their surgical rotation. On multivariate analysis, the completion of these learning activities was significantly associated with a satisfactory rotation experience (p < 0.001). Furthermore, the use of a checklist of surgical activities provided to HOs was associated with a significant increase in the performance of learning activities (p = 0.003).

CONCLUSION

Surgical HOs who were informed about potential basic surgical learning activities that can be performed during their rotations performed significantly more of these activities. And these activities were associated with a significantly greater satisfaction with surgical rotations. Therefore, we recommend facilitating HOs completion of these activities as this will ensure that basic surgical competencies are achieved and that HOs will be more satisfied with their surgical experience.

Workplace-based assessment: a review of user perceptions and strategies to address the identified shortcomings

Workplace based assessments (WBAs) are now commonplace in postgraduate medical training. User acceptability and engagement is essential to the success of any medical education innovation. To this end, possessing an insight into trainee and trainer perceptions towards WBAs will help identify the major problems, permitting strategies to be introduced to improve WBA implementation. A review of literature was performed to identify studies examining trainee and trainer perceptions towards WBAs. Studies were excluded if non-English or sampling a non-medical/dental population. The identified literature was synthesised for the purpose of this critical narrative review. It is clear that there is widespread negativity towards WBAs in the workplace. This has negatively impacted on the effectiveness of WBA tools as learning aids. This negativity exists in trainees but also to an extent in their trainers. Insight gained from the literature reveals three dominant problems with WBA implementation: poor understanding as to the purpose of WBAs; insufficient time available for undertaking these assessments; and inadequate training of trainers. Approaches to addressing these three problems with WBA implementation are discussed. It is likely that a variety of solutions will be required. The prevalence of negativity towards WBAs is substantial in both trainees and trainers, eroding the effectiveness of learning that is consequent upon them. The educational community must now listen to the concerns being raised by the users and consider the range of strategies being proposed to improve the experiences of trainees, and their trainers.

Implications of aligning full registration of doctors with medical school graduation: a qualitative study of stakeholder perspectives

OBJECTIVES

The Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis.

SETTING

Four UK study sites, one in each country.

PARTICIPANTS

185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25).

RESULTS

We identified four main themes: (1) The F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal.

CONCLUSIONS

A policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Leadership and followership in the healthcare workplace: exploring medical trainees' experiences through narrative inquiry

OBJECTIVES

To explore medical trainees' experiences of leadership and followership in the interprofessional healthcare workplace.

DESIGN

A qualitative approach using narrative interviewing techniques in 11 group and 19 individual interviews with UK medical trainees.

SETTING

Multisite study across four UK health boards.

PARTICIPANTS

Through maximum variation sampling, 65 medical trainees were recruited from a range of specialties and at various stages of training. Participants shared stories about their experiences of leadership and followership in the healthcare workplace.

METHODS

Data were analysed using thematic and narrative analysis.

RESULTS

We identified 171 personal incident narratives about leadership and followership. Participants most often narrated experiences from the position of follower. Their narratives illustrated many factors that facilitate or inhibit developing leadership identities; that traditional medical and interprofessional hierarchies persist within the healthcare workplace; and that wider healthcare systems can act as barriers to distributed leadership practices.

CONCLUSIONS

This paper provides new understandings of the multiple ways in which leadership and followership is experienced in the healthcare workplace and sets out recommendations for future leadership educational practices and research.