Toward interprofessional learning and education: Mapping common outcomes for prequalifying healthcare professional programs in the United Kingdom

INTRODUCTION

Interprofessional education (IPE) continues to be a key component in prequalifying health professional education, with calls for regulators to publish a joint statement regarding IPE outcomes. To date, the regulatory documents for healthcare education in the United Kingdom have not been examined for common learning outcomes; information that could be used to inform such a statement and to identify opportunities for interprofessional learning.

METHODS

A mapping of the outcomes/standards required by five, UK, health profession regulatory bodies was undertaken. This involved the identification of common outcomes, a keyword search and classification of common outcomes/standards; presented as themes and subthemes.

RESULTS

Seven themes were identified: knowledge for practice, skills for practice, ethical approach, professionalism, continuing professional development (CPD), patient-centered approach and teamworking skills, representing 22 subthemes. Each subtheme links back to the outcomes/standards in the regulatory documents.

CONCLUSIONS

This study identifies the key areas of overlap in outcomes/standards expected of selected healthcare graduates in the United Kingdom. The mapping provides a framework for informing prequalifying IPE curricula, for example, identifying possible foci for interprofessional education outcomes and associated learning opportunities. It allows reference back to the standards set by regulatory bodies, a requirement for all institutions involved in health profession education.

Constructing and evaluating a validity argument for the final-year ward simulation exercise

The authors report final-year ward simulation data from the University of Dundee Medical School. Faculty who designed this assessment intend for the final score to represent an individual senior medical student's level of clinical performance. The results are included in each student's portfolio as one source of evidence of the student's capability as a practitioner, professional, and scholar. Our purpose in conducting this study was to illustrate how assessment designers who are creating assessments to evaluate clinical performance might develop propositions and then collect and examine various sources of evidence to construct and evaluate a validity argument. The data were from all 154 medical students who were in their final year of study at the University of Dundee Medical School in the 2010-2011 academic year. To the best of our knowledge, this is the first report on an analysis of senior medical students' clinical performance while they were taking responsibility for the management of a simulated ward. Using multi-facet Rasch measurement and a generalizability theory approach, we examined various sources of validity evidence that the medical school faculty have gathered for a set of six propositions needed to support their use of scores as measures of students' clinical ability. Based on our analysis of the evidence, we would conclude that, by and large, the propositions appear to be sound, and the evidence seems to support their proposed score interpretation. Given the body of evidence collected thus far, their intended interpretation seems defensible.

Insightful Practice: a robust measure of medical students' professional response to feedback on their performance

BACKGROUND

Healthcare professionals need to show accountability, responsibility and appropriate response to audit feedback. Assessment of Insightful Practice (engagement, insight and appropriate action for improvement) has been shown to offer a robust system, in general practice, to identify concerns in doctors' response to independent feedback. This study researched the system's utility in medical undergraduates.

SETTING AND PARTICIPANTS

28 fourth year medical students reflected on their performance feedback. Reflection was supported by a staff coach. Students' portfolios were divided into two groups (n = 14). Group 1 students were assessed by three staff assessors (calibrated using group training) and Group 2 students' portfolios were assessed by three staff assessors (un-calibrated by one-to-one training). Assessments were by blinded web-based exercise and assessors were senior Medical School staff.

DESIGN

Case series with mixed qualitative and quantitative methods. A feedback dataset was specified as (1) student-specific End-of-Block Clinical Feedback, (2) other available Medical School assessment data and, (3) an assessment of students' identification of prescribing errors. Analysis and statistical tests: Generalisability G-theory and associated Decision D- studies were used to assess the reliability of the system and a subsequent recommendation on students' suitability to progress training. One-to-one interviews explored participants' experiences.

MAIN OUTCOME MEASURES

The primary outcome measure was inter-rater reliability of assessment of students' Insightful Practice. Secondary outcome measures were the reaction of participants and their self-reported behavioural change.

RESULTS

The method offered a feasible and highly reliable global assessment for calibrated assessors, G (inter-rater reliability) > 0.8 (two assessors), but not un-calibrated assessors G < 0.31. Calibrated assessment proved an acceptable basis to enhance feedback and identify concern in professionalism. Students reported increased awareness in teamwork and in the importance of heeding advice. Coaches reported improvement in their feedback skills and commitment to improving the quality of student feedback.

CONCLUSIONS

Insightful practice offers a reliable and feasible method to evaluate medical undergraduates' professional response to their training feedback. The piloted system offers a method to assist the early identification of students at risk and monitor, where required, the remediation of students to get their level(s) of professional response to feedback back 'on track'.

Learning from errors: what is the return on investment from training medical students in incident review?

Prescribing errors made by junior doctors are rare only due to lack of knowledge or technical skills. Final Year medical students were given the opportunity to investigate medication incidents involving junior doctors. However long-term sustainability of this activity requires evidence about return on investment for NHS Tayside who assist in supporting medical students. Kirkpatrick's model for evaluating training programmes has been adapted for evaluation of medical education. We address all four levels of Kirkpatrick's model for training medical students in incident reporting, discuss other models and emphasis the importance of return on investment. Examples of organizational learning highlighted in the pilot study suggest that incident review by medical students can provide fresh insights into achieving the “not-seeking-to-blame” culture. Incident Review is now a core activity for all final year medical students at the University of Dundee. Plans to engage with NHS Tayside in an iterative learning cycle that begins and ends with evaluation are underway.

Direct observed procedural skills assessment in the undergraduate setting

BACKGROUND

Medical students are required to undertake procedural clinical skills training before they qualify as doctors, and an assessment of these skills is a critical element of their fitness to practice.

CONTEXT

Challenges facing educators include the logistics of observing: i.e. who is best placed to assess their competence? Evidence appears to be inconclusive about the competence of students in the workplace to adhere to standards of practice, and the time required for an effective assessment.

INNOVATION

In this article the aim is to discuss who is best placed to assess final-year medical students in the workplace. We explore the use of direct observed procedural skills (DOPS) to assess students undertaking procedural skills in a simulated workplace setting by tutor-, peer- and self-assessment. The DOPS tool has been used to assess foundation doctors, but can it be used to effectively assess undergraduate medical students?

IMPLICATIONS

The main purpose of formative assessment in the simulated setting is to support student learning through the provision of feedback and debriefing. The use of the DOPS tool in this way can provide an insightful perspective of a students' assessment of procedural clinical skills. Tutors can use the DOPS tool to guide their teaching practice by tailoring their lessons towards areas in which students require more guidance. The DOPS assessment tool presents an opportunity to provide immediate and relevant feedback.

Use of proteomic patterns as a novel screening tool in pre-eclampsia

This pilot study aimed to use Ciphergen ProteinChip technology to determine differences in protein profiles in plasma, taken at 26 weeks, from women at risk of developing pre-eclampsia. Five proteins were found to be significantly up-regulated in samples from women who subsequently developed pre-eclampsia compared with women who remained normotensive.

Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT): a randomised, double-blind, placebo-controlled study and meta-analysis

BACKGROUND

Women with twin pregnancy are at high risk for spontaneous preterm delivery. Progesterone seems to be effective in reducing preterm birth in selected high-risk singleton pregnancies, albeit with no significant reduction in perinatal mortality and little evidence of neonatal benefit. We investigated the use of progesterone for prevention of preterm birth in twin pregnancy.

METHODS

In this double-blind, placebo-controlled trial, 500 women with twin pregnancy were recruited from nine UK National Health Service clinics specialising in the management of twin pregnancy. Women were randomised, by permuted blocks of randomly mixed sizes, either to daily vaginal progesterone gel 90 mg (n=250) or to placebo gel (n=250) for 10 weeks from 24 weeks' gestation. All study personnel and participants were masked to treatment assignment for the duration of the study. The primary outcome was delivery or intrauterine death before 34 weeks' gestation. Analysis was by intention to treat. Additionally we undertook a meta-analysis of published and unpublished data to establish the efficacy of progesterone in prevention of early (<34 weeks' gestation) preterm birth or intrauterine death in women with twin pregnancy. This study is registered, number ISRCTN35782581.

FINDINGS

Three participants in each group were lost to follow-up, leaving 247 analysed per group. The combined proportion of intrauterine death or delivery before 34 weeks of pregnancy was 24.7% (61/247) in the progesterone group and 19.4% (48/247) in the placebo group (odds ratio [OR] 1.36, 95% CI 0.89-2.09; p=0.16). The rate of adverse events did not differ between the two groups. The meta-analysis confirmed that progesterone does not prevent early preterm birth in women with twin pregnancy (pooled OR 1.16, 95% CI 0.89-1.51).

INTERPRETATION

Progesterone, administered vaginally, does not prevent preterm birth in women with twin pregnancy.

FUNDING

Chief Scientist Office of the Scottish Government Health Directorate.

Sources of variation in performance on a shared OSCE station across four UK medical schools

CONTEXT

High-stakes undergraduate clinical assessments should be based on transparent standards comparable between different medical schools. However, simply sharing questions and pass marks may not ensure comparable standards and judgements. We hypothesised that in multicentre examinations, teaching institutions contribute to systematic variations in students' marks between different medical schools through the behaviour of their markers, standard-setters and simulated patients.

METHODS

We embedded a common objective structured clinical examination (OSCE) station in four UK medical schools. All students were examined by a locally trained examiner as well as by a centrally provided examiner. Central and local examiners did not confer. Pass scores were calculated using the borderline groups method. Mean scores awarded by each examiner group were also compared. Systematic variations in scoring between schools and between local and central examiners were analysed.

RESULTS

Pass scores varied slightly but significantly between each school, and between local and central examiners. The patterns of variation were usually systematic between local and central examiners (either consistently lower or higher). In some cases scores given by one examiner pair were significantly different from those awarded by other pairs in the same school, implying that other factors (possibly simulated patient behaviour) make a significant difference to student scoring.

CONCLUSIONS

Shared undergraduate clinical assessments should not rely on scoring systems and standard setting which fail to take into account other differences between schools. Examiner behaviour and training and other local factors are important contributors to variations in scores between schools. The OSCE scores of students from different medical schools should not be directly compared without taking such systematic variations into consideration.

Cross-referencing the Scottish Doctor and Tomorrow's Doctors learning outcome frameworks

Learning outcomes, organised into systems or frameworks which describe and define the output of an educational programme, are being created and used in healthcare education with increasing frequency (Harden 2001, 2002). Medical schools may be required to conform to more than one such outcome framework. For example, both the UK General Medical Council (GMC) and the Scottish Deans' Medical Curriculum Group (SDMCG) have created and published a systematic learning outcome framework for medical graduates. Although both of these publications are concerned with undergraduate medical education, they differ in their aims, and structure. In order to use, evaluate and validate them, a cross-referencing system which relates each learning outcome statement, term or groups of terms is required. This paper describes the cross-referencing exercise undertaken by the SDMCG, the philosophy behind it, the practical steps taken, the findings, the lessons learnt and reflections upon how this work may be taken forward. It will be of interest to all those who are involved in curriculum development using outcomes, and especially those who use the GMC's Tomorrow's Doctors or the SDMCG's Scottish Doctor frameworks and those who are interested in education informatics in general.

Changes in Endothelial Function Precede the Clinical Disease in Women in Whom Preeclampsia Develops

Endothelial dysfunction is important in the pathophysiology of preeclampsia. No study has examined endothelial function sequentially at different gestations before development of the clinical syndrome and after delivery (to compare maternal from placental influences). We sought to determine whether endothelial function changes before the clinical development of preeclampsia. We measured skin microvascular function using iontophoresis of acetylcholine and sodium nitroprusside, and laser Doppler imaging at 22, 26, 34 weeks' gestation and 6 weeks postpartum in women identified as being at increased risk of preeclampsia, based on uterine artery Doppler waveforms at 18 to 20 weeks, and controls with normal Doppler waveforms. Fifty-four women remained normotensive and preeclampsia developed in 15. In normotensive and preeclamptic women, acetylcholine responses were augmented during pregnancy compared with postpartum responses (P<0.001). Sodium nitroprusside responses were augmented during pregnancy compared with those postpartum (P<0.005) in preeclamptic women only. Microvascular responses were augmented in women in whom preeclampsia developed, compared with those in normotensive women, at 26 and 34 weeks for acetylcholine (P<0.05 and P<0.001, respectively) and at 22 and 26 weeks for sodium nitroprusside (P<0.05 and P<0.02, respectively). Postpartum acetylcholine and sodium nitroprusside responses were not significantly different between preeclamptic and normal women. Microvascular responses are enhanced during pregnancy in women in whom preeclampsia develops to a level above that seen in normotensive women. These changes precede the onset of clinical disease and might be related to a compensatory increased sensitivity of the microcirculation to nitric oxide.

Altered endothelial function in isolated human myometrial vessels induced by plasma from women with pre-eclampsia is not reproducible in isolated mouse vessels

In order to facilitate characterization of the circulating factor(s) in pre-eclampsia, the present study aimed to determine whether plasma from women with pre-eclampsia, which induces attenuated endothelial-dependent relaxation in human myometrial arteries, is also capable of inducing altered endothelial function in mouse vessels. Human vessels were isolated from myometrial biopsies taken from women with uncomplicated pregnancies (n = 6). Mesenteric and uterine arteries were isolated from male, female, non-pregnant and pregnant C57B mice (n = 24). Vessels were studied using a wire myograph and incubated with plasma (2%) from women with pre-eclampsia (n = 12) or controls (n = 12). Incubation of myometrial vessels from normal pregnant women with plasma from women with pre-eclampsia reduced endothelial-dependent relaxation. This effect was not reproduced in male or female mouse mesenteric or uterine vessels incubated with plasma from women with pre-eclampsia. In conclusion, there are species-specific differences in the actions of the circulating factor(s) on endothelial-dependent relaxation of human and mouse small arteries.

In Preeclampsia, the Circulating Factors Capable of Altering In Vitro Endothelial Function Precede Clinical Disease

The pathophysiology of preeclampsia involves the release of a circulating factor(s) from a hypoperfused placenta that activates the maternal endothelium. This study investigated the effect on in vitro endothelial function of plasma taken from women in whom preeclampsia subsequently developed. Women at increased risk for an adverse pregnancy outcome were identified using Doppler waveform analysis. Plasma samples (22 and 26 weeks) were incubated with myometrial vessels taken from women with uncomplicated pregnancies. Wire myography was used to study the effect of plasma on the endothelium-dependent vessel behavior. Incubation of vessels from normal pregnant women with plasma from women in whom preeclampsia subsequently developed (n=19) significantly reduced endothelium-dependent relaxation, compared with vessels incubated with plasma from normal pregnant women (n=48). This effect was demonstrable for plasma taken at 22 weeks (residual constriction 47.1±6.6% versus 32.0±4.4%, P =0.004 at 1-hour incubation; and 59.1±8.4% versus 42.3±5.9%, P =0.001 at 18-hour incubation) and 26 weeks (59.2±5.2% versus 29.1±5.6%, P <0.001 at 1 hour; and 63.3±7.6% versus 31.9 +/-7.2%, P <0.0001 at 18 hours). Endothelial-dependent relaxation was unaltered after incubation with plasma taken from women in whom normotensive intrauterine growth restriction subsequently developed (n=19). This study supports the hypothesis that plasma, from women in whom preeclampsia develops, collected weeks before diagnosis is capable of altering endothelial function.

Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population

OBJECTIVE

To compare the effect of admission cardiotocography and Doppler auscultation of the fetal heart on neonatal outcome and levels of obstetric intervention in a low risk obstetric population.

DESIGN

Randomised controlled trial.

SETTING

Obstetric unit of teaching hospital

PARTICIPANTS

Pregnant women who had no obstetric complications that warranted continuous monitoring of fetal heart rate in labour.

INTERVENTION

Women were randomised to receive either cardiotocography or Doppler auscultation of the fetal heart when they were admitted in spontaneous uncomplicated labour.

MAIN OUTCOME MEASURES

The primary outcome measure was umbilical arterial metabolic acidosis. Secondary outcome measures included other measures of condition at birth and obstetric intervention.

RESULTS

There were no significant differences in the incidence of metabolic acidosis or any other measure of neonatal outcome among women who remained at low risk when they were admitted in labour. However, compared with women who received Doppler auscultation, women who had admission cardiotocography were significantly more likely to have continuous fetal heart rate monitoring in labour (odds ratio 1.49, 95% confidence interval 1.26 to 1.76), augmentation of labour (1.26, 1.02 to 1.56), epidural analgesia (1.33, 1.10 to 1.61), and operative delivery (1.36, 1.12 to 1.65).

CONCLUSIONS

Compared with Doppler auscultation of the fetal heart, admission cardiotocography does not benefit neonatal outcome in low risk women. Its use results in increased obstetric intervention, including operative delivery.

Antenatal provision of additional information about the role of students in the labour suite and their subsequent involvement in care: a randomised controlled trial

To determine whether the antenatal provision of additional information to pregnant women about the roles of medical and midwifery students in the labour suite increases their actual and theoretical involvement in care during labour, 624 pregnant women booked for delivery at Ninewells Hospital and Medical School, Dundee were randomised at 34 weeks gestation to receive either a specifically produced information leaflet through the post on the roles of medical and midwifery students in the labour suite, or no additional information. Post delivery and following discharge, women were asked to complete a questionnaire about people who were involved in their care during labour. There were no significant differences in a women's willingness (actual or theoretical) to have medical or midwifery students involved in their care between women who received additional information and those who did not. Of those women who had a student present during labour, midwifery students were significantly more involved in all care activities than medical students (p<0.01 for all activities), with the exception of vaginal examination. Women who did not have a student present because one was not available, but who indicated that they would have allowed a student to participate in their care if one had been available, were significantly more likely to allow a midwifery student to perform vaginal examinations, assist with delivery and attend the baby than medical students (p<0.01 for all activities). They would allow equal participation in other activities. For both groups of students, these women appeared to be willing for significantly more active involvement in care than is happening in practice.

Obstetric outcome of natural and assisted conception twin pregnancies is similar

BACKGROUND

The risk of obstetric intervention and adverse fetal or neonatal outcome is considerably higher in multiple gestation than in singleton pregnancy. How assisted conception influences obstetric management and outcome in twin pregnancies has not been evaluated.

METHODS

A survey of all twin pregnancies in Iceland and the Tayside Region, Scotland for a four year period, 1990-93, comparing twins after assisted fertilization with natural conception.

RESULTS

The total number of twin pregnancies was 522, of which 453 were natural conceptions and 69 assisted. The twin rate was 1:75 among natural conceptions, but 1:5 in women having assisted fertilization. Mean gestational age in both groups was 36 weeks. Elective Cesarean section was used more often in the assisted conception group (odds ratio 2.57; p = 0.003). Induction rates did not differ to any significant degree and once labor commenced, no difference was seen between assisted and natural conception twins in the mode of delivery or neonatal short term morbidity. Birthweight, gestational length and perinatal mortality rates by conventional and extended classification were not different.

CONCLUSION

After allowing for more frequent elective Cesarean section in the obstetric care of the assisted conception pregnancies, there was no major difference in obstetric and neonatal management or outcome between twins resulting from natural and assisted conception.

The effect of fetal heart rate on umbilical artery flow velocity waveforms

Umbilical artery flow velocity waveforms were obtained using continuous wave Doppler ultrasound in 85 normal pregnancies (25 antepartum, 60 intrapartum) to examine the relation between fetal heart rate, end systolic/end diastolic ratio (A/B ratio) and resistance index (RI). Our results demonstrated a significant negative correlation between fetal heart rate, A/B ratio and RI (in the antepartum group r = -0.49, and in the labouring group r = -0.65). It is therefore important when performing mathematical analysis of umbilical artery flow velocity profiles to make a statistical allowance for fetal heart rate.