Mapping the learner pathway
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Final Draft – Confirmed at research sites 5/7/2008
Mapping the learner pathway – A report for Kent Surrey and Sussex Deanery for Postgraduate Medical and Dental Education – May 2007 Contents
1.1 Acknowledgements 1.2 Executive Summary 2 3 4 5 6 7 8 9 Introduction Methods The emphasis of the Foundation Programme. Induction The Pattern of Need on the Learner Pathway Confidence and competence Careers advice, guidance and information Clinical and Generic Professional skills
2 2 4 4 5 7 8 10 12 14 16 18 20 21 22
10 Assessment 11 Library and Information Services 12 Conclusions 13 Suggestions References
Author: David Wood
David Wood 2007 +44 (0)1869 321380 mob: 07903 671703 davidwoodconsultants@talktalk.net
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Final Draft – Confirmed at research sites 5/7/2008 1.1 Acknowledgements
The author wishes to acknowledge the generosity, co-operation, and cordiality of the staff at the two hospital sites during the data gathering for this evaluation. Particular thanks are due to the new doctors who participated in the study and the hospital staff who scheduled the programme of interviews at each site.
1.2
Executive Summary
KSS Deanery commissioned this study to determine whether common elements of a ‘learner pathway’ can be identified now that the Foundation Programme (FP) is becoming established. This study is designed to ask: a) what are the needs of Foundation Programme doctors, as learners, during the different stage(s) of the Foundation Programme; b) c) d) where they go to find appropriate information and resources; is existing provision appropriately matched to their needs; what makes a good learning experience?
The study was conducted in a six week period at two hospital sites. There were 17 semi-structured interviews with ‘providers,’ teaching and managing the FP and two focus group discussions at each site with a total of around 30 first year Foundation Programme (F1) trainees, of whom 23 volunteered to keep an email diary of their learning experiences for the six weeks between the first and second focus group interviews. In practice only a small minority emailed diary entries. Most trainees and providers believe that the core of the programme is the learning opportunities or ‘affordances’ which arise in daily clinical care. Despite this, less than a third of the trainees identified and recounted specific learning events during the six weeks. As the year progressed, trainees recognised and appreciated the contribution of the scheduled teaching sessions for all trainees more. Providers placed a high importance on formal induction to the FP, whilst trainees believed a clear introduction to Trust and hospital policies is their most pressing need during induction. The repetition of basic skills training at induction was a source of frustration to some trainees. Trainees need the most support during the first 4-6 weeks of the Programme and the first two weeks of each rotation. F2 needs are tightly focussed around career choices and the specialty training applications round (MTAS) as the second year progresses. Trainees experienced pressure to complete assessments and expressed concerns about the truncated period in which to do them in the final rotation of the year. At least seven trainees claimed that they gained considerable confidence when given, sometimes by default, increased independence and autonomy.
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Final Draft – Confirmed at research sites 5/7/2008 Trainee views about careers information and guidance were significantly affected by the introduction of MTAS during the period of the study. Most providers counselled against basic careers guidance, for example about form filling. Trainees almost unanimously valued careers sessions led by specialty registrars and consultants, and favoured careers sessions as early as possible during the FP. Providers highlighted trainee resistance to the teaching of generic skills and this was corroborated by the majority of trainees. Providers are beginning to favour the use of role play and other learning methods which integrate clinical and generic skills. There were widespread concerns about the assessment system. Trainees almost unanimously perceived it as ‘bolted on’ to real learning. At least one provider at each site was unconvinced that the assessment system differentiated adequately. However, another provider was confident that the system would work well once the FP was more established. This provider also advocated a smaller cadre of Educational Supervisors, selected on the basis of their advocacy of and confidence in the FP. Library and Information Services staff wished to make a more substantial contribution to the programme. Two of these staff interviewed pointed out that trainees made extensive use of Google for medical sources and so should be given more training in effective literature searching skills.
The study suggests that staff delivering the Foundation Programme in the KSS region could usefully exploit this account of the learner pathway by addressing one or more of eight suggested strategies involving:
I. II. III. IV. V. VI.
assessment; library and information services; assembling pre-course information; creating integrated materials for developing clinical and generic skills together; delaying induction; reviewing on-call rotas for trainees, balancing the European Working Time Directive (EWTD) and supervised practice against trainee gains in confidence, independence and the acceleration of expertise;
VII. VIII.
managing trainee expectations; managing change and misgivings about the FP.
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Final Draft – Confirmed at research sites 5/7/2008 2 Introduction
Following the Chief Medical Officer’s proposals in ‘Unfinished Business,’ (2002), the Foundation Programme for new doctors was introduced across the country in August 2005 when the first cohort of graduates from medical school entered the Programme.
Prior to this development the Kent, Surrey and Sussex (KSS) Deanery set up Foundation Programme pilots. The evaluation of these, (Dewhurst, Shaw & Wood: 2006) highlighted areas of emerging good practice. With the added experience of the first two cohorts going through the Foundation Programme, the study which follows is designed to address the following questions: a) what are the needs of Foundation Programme doctors, as learners, during the different stage(s) of the Foundation Programme; b) c) d) where do they go to find appropriate information and resources; is existing provision appropriately matched to their needs, what makes a good learning experience?
By collecting information about these issues, the study is designed to uncover a picture or map of the learner pathway through the Foundation Programme in two hospitals representative of the KSS region. It is hoped that the emerging picture will serve to inform the consolidation and refinement of the Foundation Programme in the KSS region.
In the text which follows, Foundation Programme doctors are referred to as ‘Trainees.’ The Foundation Programme lead staff - Medical Education Managers, Educational Supervisors and other staff providing the training - are referred to as the ‘providers.’
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Methods
The study was conducted between March & May 2007 at two hospitals in the KSS region who agreed to take part. It therefore offered a sharply focussed insight into the development of learning for a group of year one trainees over a period of six weeks. Furthermore, the interviews with providers probed more general observations about the pattern of the learner pathway during the entire two years of the Foundation Programme.
The research was designed to provide multiple perspectives on the learning experience of the Foundation Programme. The research methods, therefore,
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Final Draft – Confirmed at research sites 5/7/2008 comprised semi-structured interviews with 17 providers including a Director of Medical Education, Medical Educational Managers, Foundation Programme leads, Education Supervisors, Clinical Supervisors and Knowledge Services Managers and their library colleagues, as well as Foundation Programme administrative staff.
3.1
At each site two focus group discussions took place with a representative
sample of year one (F1) trainees, one at the beginning and one at the end of the sixweek period. Each of the four discussions lasted around 45 minutes and, although trainees were sometimes ’bleeped’ to return urgently to wards, approximately 30 trainees from the 2 hospitals participated in the discussion at various points.
3.2
Following the first two focus group discussions, a total of 23 trainee
volunteers were asked to keep an email diary of the opportunities for learning they encountered during the following six weeks. Trainees were emailed a reminder about the e-diaries each week, but in practice only a small amount of data was collected by this method. Nevertheless, four of the volunteers emailed accounts of ‘critical incidents’ in their learning, all of which are described below.
3.3
The study also involved scrutinising documentation associated with the
Foundation Programme, both at a national level in documents such as the ‘Rough Guide to the Foundation Programme,’ (2005) and at each of the study sites in handbooks, curriculum documents and timetables.
4 4.1
The emphasis of the Foundation Programme Almost all of the individuals interviewed agreed that the principal objective of
the Foundation Programme is competency in clinical practice and in acute medical care. This aligns well with key objectives of the Programme as articulated by the Foundation Programme Committee (2004).
Trainees believed the programme essentially comprised the learning opportunities or ‘affordances’ which happen in daily practice:
It’s up to your seniors on the wards to be pro-active in your teaching. Luckily I’ve had one very good consultant.
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Final Draft – Confirmed at research sites 5/7/2008 The majority view was that learning is gained and consolidated by experience and attempts to provide a scheduled teaching programme are supplementary to the learning affordances gained from clinical work.
4.2
Each site provided a schedule of teaching sessions each week, as required
by the Foundation Programme curriculum. However, there were different approaches in the two different sites. For example, one site favoured shorter and more regular sessions; the other scheduled longer less frequent ones. The decision to stage longer sessions at one site was positively viewed by F2 trainees who did not like twice weekly lunchtime sessions. At one site the F1 teaching schedule centred on acute care, and involved key lecturers such as anaesthetists and surgeons to deliver the programme. Their F2 teaching schedule put more emphasis on generic skills, such as ethical issues, completing the most common forms and effective writing for a range of professional purposes. One provider expressed the view, that – on reflection – an integrated approach to teaching clinical and generic skills is preferable, and this approach was more often used at the other site. Another provider attached particular importance to longer teaching sessions believing that they make: Learning more of a workshop, more of a two-way discussion and not just sitting down listening to a lecture which is not the way to be teaching anybody.
In the first focus group interview, the majority of trainees felt that the teaching sessions made a very small contribution to their learning, serving as a distraction from the wards. However, by the second focus group interview, there was a significant shift to the view that the weekly scheduled sessions were becoming much more useful. Now we’re getting registrars and consultants coming in and speaking to us about their specialties and common things we’d see on the wards and their management…
4.3
A curious phenomenon is that, although the trainees unanimously agreed with
the proposition that nearly all learning happened through affordance and opportunity on the wards and in practice, fewer than ten critical learning incidents were recounted by the 30 trainees over the six weeks. Research by Wagenaar et al (2003) concluded that affordances are not recognised as real learning or exploited as such. This may explain the low number of learning events recounted by trainees in journals and in interviews. One provider had noticed this phenomenon:
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Final Draft – Confirmed at research sites 5/7/2008 [With] three hours a week protected teaching time the [trainees] only think they’re getting their learning then and not otherwise. And yet the learning on the job ought to be more fulfilling and more useful.
5 5.1
Induction One site has a full day induction for F1s and a full day for F2s. At the other
site there are 3 days of induction for F1s. There is also a trust-wide induction and, at the beginning of each rotation, induction related to each particular specialty.
One provider judged induction as a critically important element of the orientation exercise: Whatever we do, even if we give them a week for induction it’s not enough. It’s just a flavour. It’s not addressing the important issues.
The same provider believed, however, that the August start to the programme militated against effective induction: 40% of the workforce will be on leave! There can’t be any worse time to start. In [another country] they used to change in January and June, a much better time.
One trainee advocated a system where new trainees would shadow a more senior doctor for the first month of the first rotation, before having the hospital induction and taking more responsibility. Other trainees in this focus group liked this idea in
principle, but pointed out the cost implications and the need to take annual leave as well during the summer months.
5.2
About half of the trainees advocated a clear introduction to Trust and hospital
policies during induction. They believed that more information on the local approach to, for example, prescribing drugs such as Warfarin, expectations of on-call and the pain relief ladder, would have been very useful at induction. Trainees at the other site also claimed that their most pressing initial need was to find out about the Trust’s expectations of a trainee on call. One trainee advocated e-learning before induction as the best medium for communicating Trust and hospital policies, protocols and expectations, so that the induction itself could focus on practical skills. Others agreed saying that a new trainee is expected to follow trust policies on, for example, prescribing, on-call periods or how to respond to certain situations, from their first day without necessarily knowing the policies in question. Trainees primarily felt that a list of on-call responsibilities would have been useful during induction.
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Final Draft – Confirmed at research sites 5/7/2008
5.3
The repetition of basic skills training at induction was a source of frustration to
some trainees and providers were aware of this: When they do canulation, some say ‘we did that at medical school.’ But we have F1s from different medical schools and different parts of the world. So they have to consolidate.
There were clear differences of opinion on this point in the interviews with trainees at one site. One trainee stressed the need for canulation training at induction while another expressed surprise that this had not been covered by all trainees at medical school. One trainee wrote an e-diary entry on the benefit of revising material learned as a student doctor: Today I was on the ward while the medical students were having their weekly bedside teaching session. I was able to listen in on the teaching and learnt a lot about presenting X-rays and examining patients. It was a good revision of things I knew well for finals but perhaps do not have the time to study now. It would be useful if F1s could have this kind of teaching. Being taught interactively on the wards seems much more relevant and interesting than lectures.
One of the sites had appointed a group of overseas trained doctors. The providers had learnt not to take certain competences for granted. For example, common practice in one EU country outside the UK is for nurses rather than doctors to take blood. Similarly, overseas trained doctors tended not to have practical experience of canulation. For this reason the hospital had introduced a two week pre-induction programme for trainees from overseas: To give them some flavour and so they know the system and so forth and it works to our advantage but it comes with some pressures: ie someone needs to assess the two weeks; we need people to be shadowed…
5.4
One trainee felt that more practical rather than theoretical skills should be
offered during induction, citing the baptism of fire she experienced when suddenly responsible for Warfarin dosing. A majority of the trainees at this site agreed, pointing out that this was the first time they had been responsible for decisions on a ward. You go to each ward and there is always a list of things to do and you just think ‘should I be doing this, should a senior colleague be doing it, should I leave this for the team for the next day?’ I know it’s up to us to prioritise but you do find yourself doing things which you perhaps shouldn’t be doing.
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Final Draft – Confirmed at research sites 5/7/2008
6 6.1
The Pattern of Need on the Learner Pathway Virtually all providers and trainees independently identified the first four to six
weeks of the Programme and the first two weeks of each rotation as the most pressing periods of need for trainees. This matches research by Radcliffe & Lester (2003) which identifies the transition from student to apprentice doctor as the most frequently cited stressful period in medical training.
6.2
The pressure to submit Foundation Programme assessments dominated the
needs of some F2s, one provider reported. Virtually all providers said that the needs of F2 trainees become concentrated on career choices as the year progresses: Their priorities shift radically as the next rotation approaches and they think about how they will get the next job.
The most important need is how F2s can get into Specialty Training and how to make a successful application.
This may explain one provider’s view that neediness increases as the end of a rotation approaches.
Another provider emphasised the pressing need trainees felt by mid-May to complete assessment. According to this provider, the administrators needed to chase the majority of trainees for completed assessments and some had not even submitted the educational agreement from the start of the programme. The explanation was that trainees perceived paperwork as an irritating distraction from patient care. The provider, however, stressed that new doctors needed to get used to a professional environment in which paperwork was an indispensable part of records and professional practice, and this was echoed by one other provider: You can’t be a doctor if you’re not very good at paperwork.
A trainee anticipated the distinct pressure of starting the F2 year: In August we begin F2 and…for a lot of people prior to that we’ll have only had four months’ experience of medicine and yet I’ll be the medical SHO on call. I feel it’s a big jump. So much more responsibility comes with it.
6.3
Both trainees and providers pointed out that each year of the Foundation
Programme comprises, in effect, a nine and a half month programme of two four
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Final Draft – Confirmed at research sites 5/7/2008 month rotations and a final one for which assessments have to be completed within six weeks in order to be processed by the national system. One provider noted that some F1s were doing three month rotations so allowing the completion of three full sets of assessment and a rotation during which to consolidate. On the other hand, three month rotations allowed less time to develop competence and confidence. One provider suggested structuring the Programme as four sections of six-months, comprising 18 months acquiring competences in medicine, surgery, GP and A&E and sub-specialties within them as well as getting assessments signed off, and devoting the last six months to career planning: …Instead of what is currently happening, this enormous pressure at the end. They’ve got to move, they’ve got to get signed up, they’ve got to get a job, they’ve got to do an audit presentation and so forth…
6.4
One provider drew attention to the needs of the trainees who are most
focused, driven and well-organised: Those who are doing quite well by the system but are still ‘system bashing.’
Trainees who are: Very stressed about ‘am I going to get on the surgical training programme and is the job going to be as I expect in 5 years time’... so their stresses are different depending on the kind of personality they are.
Another distinctive view was that trainees’ most pressing need at the beginning of the FP is to adjust to professional demands: Timekeeping, the fact that they’re working, time management are all things they need right from the word go. They are more focused on knowledge rather than professional development and the two go hand in hand. We shouldn’t need [a dress code policy] For this interviewee, this professionalism might take a few months to develop in trainees though the most mature might develop it in two weeks or so. This view aligns well with Boshuizen et al (2004) who cite six different studies in which new doctors report difficulty prioritising, and lack of experience in organisational skills.
7 7.1
Confidence and competence A provider expressed concerns that the European Working Time Directive
had resulted in an unintended overprotection of trainees, ‘wrapping them in cotton
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Final Draft – Confirmed at research sites 5/7/2008 wool.’ This provider felt that the Foundation Programme should avoid spoon feeding and instead make challenging demands of the new recruits: We have finally started our [trainees] to be on call at night and they…were a bit upset about it because they had to do it but after they did a week of nights I’ve had feedback saying ‘that was so good because I have increased in confidence.’ Trainees at one hospital regretted the fact that they were not given the opportunity to work nights during their F1 year, since so much experience could be gained from working night shifts.
Independently, trainees made several comments about this issue. Seven comments, volunteered in interviews and e-diary entries, were about autonomy and arm’s length supervision resulting in an accelerated growth of confidence and expertise, especially when circumstances forced the trainee to take more responsibility.
I recently worked a week of nights with a [Senior House Officer] who has a reputation for being unsupportive to juniors. I anticipated learning next to nothing. In reality, although I rarely saw my SHO (and when I did his advice was not helpful) I learnt more in that week than any other… This was because I was faced with scenarios that needed my intervention. My choice was to do nothing and wait for the SHO, or get on with it and hope that what I did would work. It turned out that much of what I was doing was right. The things I didn’t know, I would quickly look up. The week boosted my confidence no end. I think this illustrates that doing and seeing is the best way to learn.
7.2
This view was tempered by one trainee who pointed out that medicine is not a
profession where it is often appropriate to learn by trial and error, but by observing practice. Nevertheless, a small group of trainees described a set of problems involving staffing in a particular firm. Whilst they expressed dismay about the lack of supervision and guidance they had received as a result of the difficulties, they were unanimous in concluding that this had been a useful learning experience. These trainees had needed to take on more responsibility and this had boosted their confidence and accelerated their skill acquisition.
Conversely, one trainee recognised the dangers of abrogating responsibility when under close supervision: When you’ve got a senior by your side you lose the capability to think…you become lazy, mentally, and when you haven’t got a senior there you have to think.
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Final Draft – Confirmed at research sites 5/7/2008 One provider suggested that GP rotations strike an ideal balance between independence and supervision. Because of the structure of GP work, it was claimed, there is more time for 1:1 supervision as well as mentoring and pastoral support within a context in which the trainee regularly runs clinics independently.
Providers noted a pattern of increased confidence towards the end of a rotation and agreed that need diminished towards the end of four month rotations. Two providers and several trainees pointed out that four month rotations are not long enough for trainees to consolidate the new skills they have learnt before they move on. One cited a case in paediatrics where a trainee had raised concerns - correctly - about a case of child abuse. This had given the trainee notable new levels of confidence and self-esteem.
8 8.1
Careers advice, guidance and information It should be emphasised that attitudes to careers were significantly affected
by the precise period during which the study was conducted. The introduction of competitive entry into specialties after the FP radically changed the expectations of new doctors. The Department of Health’s difficulties introducing the specialty training application process (MTAS) led to jaundiced views of careers guidance and information whilst conducting the research. This very point was raised and acknowledged by two trainees during the second focus groups discussions, and by three providers.
8.2
Nonetheless, KSS Deanery staff recognised that careers information and
guidance had become an increasing priority for them since the late 1990s. The Deanery now stages a half-day training course for Educational and Clinical Supervisors on providing careers information, guidance and advice as well as a resource book. At one site two sessions are provided for F2s and one for F1s. One site had a careers afternoon for all Foundation Programme trainees, so each year could harness the skills and knowledge of the other. In addition careers guidance plays a part in the three meetings between Educational Supervisor and trainee each year, and providers expect to give regular informal advice on a one to one basis.
Providers expressed some frustration about their access to MTAS information during this period:
We have spent a lot of time on this; probably more than we expected.
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Final Draft – Confirmed at research sites 5/7/2008
I can’t tell people how to apply if I don’t know what they are looking for in the application.
If they tell me the chance of X person getting into a specialty is 1000 to 1, I’ll advise them not to apply. If someone, for example, is going into xx specialty, what is the chance of them being interviewed? For example, if you look at KSS, a large area, only 30 trainees are to be appointed [in xx specialty].
Shortly after period during which the research was conducted, however, this sort of demographic information became available
8.3
Two interviewees expressed concerns about the low level of some careers
guidance. One provider, whilst noting trainee concerns about application processes, felt that to provide basic advice was unnecessary: I think they are beginning to stand on their own two feet and I’m not sure you need to tell them how to fill a form in.
A further provider believed that informed decision making should be the prime objective of careers sessions: You’ve got to think about the lifestyle that this career choice would involve against that career choice and I think that’s much more important. I don’t think people need four sessions to fill out an MTAS form when they’re fairly self-explanatory.
A trainee at one site was also disappointed about the level of a careers session. We had to cut and paste adjectives and put them into boxes.
However, another provider cited anecdotal responses from F2s that such baseline guidance was improving their application skills and chances of success in competition for specialty places.
There was a consensus that careers information and guidance was useful in the dedicated teaching sessions as early as possible. What you do in these 2 years affects your chances of getting on to what you want to do in the future.
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Final Draft – Confirmed at research sites 5/7/2008 The KSS Deanery was introducing such work at earlier stages during the study and also supported the introduction of more careers work during undergraduate courses.
Trainees almost unanimously favoured careers sessions in which senior staff in various specialties, ‘such as surgeons and anaesthetists’ talked about what they did and the routes and decisions they had taken. Two providers agreed and reported a trend to schedule more of this type of session in the near future.
9 9.1
Clinical and Generic Professional skills We have to balance and we try our best to balance between generic and
clinical care.
Interviewees often commented on the tension in the Foundation Programme between clinical and ‘generic’ skills. The latter phrase denotes the broad range of professional tasks outside clinical processes and procedures. It includes functions like communication with families and spouses, completing death certificates, medical ethics and other issues. The fact that this broad range of tasks are all grouped under the title ‘skills’ in MMC terminology and everyday discourse may imply that this area of professional development warrants more scrutiny and thought.
Most providers believed that trainees are resistant to generic skills teaching: Whenever you do that you get them asking, ‘why are we doing that? We want more clinical work. We want to be working in the ward.’ But when they get to that level they will need [generic skills].
A lot of them say I don’t need that, what are you teaching that for?
That’s where needs conflict because we are trying to give them a generic programme where they say tell me what I need to know today…
Providers gave specific examples of this tension: For example: filling in a death certificate. It’s very important. Unfortunately they will have to do that. And we get reports that people are not filling them in properly. So we have to go back and see that they have to do it. Have to learn how to do it.
At another site a provider raised the same topic.
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Final Draft – Confirmed at research sites 5/7/2008 We’ve had a circular here asking if we can include death certificates earlier on. The problem is you need to include…the unconscious patient, everyone wants to be taught about diabetes, they want to be taught about managing hypertension on the wards, pre-op assessment and they all want to be taught that in the first week! And if you are on a diabetic firm you don’t need a lecture on diabetes whereas on surgical you do need that lecture on diabetes because you’ve got a pre-op patient you’ve got to prepare for theatre and get that diabetes sorted out.
One provider drew attention to the internal contradictions he faced in trainee feedback about generic skills. They love practical things like suturing. [And yet when] I did a session for ethics and law and they loved it, but often they say [beforehand] ‘we don’t need that.’
9.2
To illustrate the complexity of generic skills development, another provider
described how she conducts interviews with families and instructs trainees to stay with the nurse and the family after she leaves because of the change in the dynamics this precipitates. In her view, the family adopt a more informal approach and ask more questions without the presence of the consultant, and this illustrates the potential for the doctor to be unconsciously intimidating. This provider believes it is important for the trainee to observe and reflect on the effect doctors have on patients and their families, observing: Communication skills with a family is much harder than doing a canula.
This provider cited a case in which a family had wrongly blamed an F2 trainee for a clinical decision the trainee hadn’t herself made. This had been a unique situation which challenged her approach to professional conduct.
An F1 trainee emailed an account of a similarly challenging situation:
I was called to see a patient who had xxx – this patient had been refusing any medical intervention. The patient’s wife confronted me in a very aggressive manner, demanding to know why her husband has been put through all of these investigations while in hospital and asking me, “Why can’t we just leave him alone and let him go home?” I was completely astounded by her manner and demands at first. Then I tried to explain to her that I was the doctor on call, therefore this was my first encounter with this patient, and I was called to see him because the nurses were concerned about his condition. The wife persisted in her tearful accusations. I then very firmly
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Final Draft – Confirmed at research sites 5/7/2008 told her that she must address such concerns with the team responsible for her husband’s care. In the end, she seemed to understand my point and decided to speak to the team the following day. The experience was difficult for me as I am a very gentle person by nature, but at the same time showed me that I need to take charge in such situations and that when need be, I can actually do it.
9.3
One provider advocated an integrated approach::
It’s very hard for a learner to know what they need to learn. They have a perception of what they need to learn. But they have to know about other things and it’s difficult to introduce it without them feeling very negative about it. [But] if it is part of an afternoon about trauma…you can bring in talking to somebody who’s a distressed relative. So you’re not learning communication in isolation to everything else.
It’s just a question of re-badging, re-packaging it more so that they will be learning about the clinical situation and applying these generic skills in practical ways.
Another provider advocated role-play as a means of integrating generic and clinical skills in the Foundation Programme. The use of volunteers (PALS) as patients allowed trainees to practise case-based discussions, and to see the importance of some generic skills, such as talking to relatives and spouses. It also allowed the trainees to bring their own experiences to the case. Unprompted, F1 Trainees mentioned that this learning method was a valuable one. Another provider expressed an aspiration to begin to use this, although his hospital was not currently using it.
9.4
Lave & Wenger (1991) advocate this sort of approach as an authentic
variation on their situated learning theory, designed to bridge the theory-practice divide. Säljö’s (1979) research into levels of adult learning led to his model of five levels of learner maturity. The above practice aligns well with Säljö’s levels four and five in which the learner makes sense or abstracts meaning by relating different elements of subject matter to the real world. We have to go with the curriculum; to make sure they have a balance. Generic teaching has to be there. They [trainees] are more likely to ask for more acute rather than generic teaching.
All the above suggests that an important development of the Foundation Programme will be to manage the expectations of the trainees. Trainees are more likely to
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Final Draft – Confirmed at research sites 5/7/2008 perceive themselves as journeymen and women perfecting a set of skills, rather than recognising the key contribution of generic skills to their development.
10 10.1
Assessment Nearly every trainee believed that the national assessment system for the
Foundation Programme is an extraneous process, which adds nothing to the learning experience and constitutes an irrelevant burden. The assessments we do are farcical and contrived… Its just a hoop to jump through. This attitude is enacted in the difficulty in gathering in assessments which administrators reported.
On the other hand one provider believed that F1s enter the programme with a conscientious approach to completing assessments and: As time goes on they become less bothered by it. Because nobody didn’t get signed off last year they assume that if they don’t do them it will all be fine. It’s a paper exercise, I don’t think it’s taken terribly seriously, it’s very labour intensive…they should do in a few in each and every rotation but they don’t, they save them up to the end so it makes it a waste of time really. If the system is going to continue we need to have the teeth to say you...will have to start your F1 year again.
One or two trainees had a different perspective: I learnt the most I ever learnt clerking someone in MAU and then we sat down and presented it to a registrar and he talked me though it. And it happened to be a [CaseBased Discussion] but I didn’t go to them and say can we have this as a CBD and she taught me loads and it took about 15 minutes.
When it’s done properly it probably is quite beneficial but otherwise it’s so hard to get that time.
Another trainee seemed to see the irony of an unpopular assessment system which, potentially, could be seamlessly integrated into learning:
The silly thing is you do it every day on the ward round, you discuss cases…you see people. You have to pin people down for a silly piece of paper that doesn’t actually count for anything.
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Final Draft – Confirmed at research sites 5/7/2008 Trainees favoured Case-Based Discussion (CBD) as the most relevant and useful form of assessment but claimed, as did providers, that the electronic submission of CBD assessments is inconvenient. For trainees it was difficult enough to interrupt a busy consultant schedule to do the assessment and the electronic submission system and password access compounded the barriers to completion. One or two trainees and providers pointed out that staff in other medical professions could also sign off assessments.
10.2
Two providers expressed doubts about whether the system could differentiate
effectively between trainees. Trainees were aware of this too:
If you get a bad form, you don’t have to submit that form…you’d submit your six best assessments. If someone’s not very good they could probably find six people that will just tick away at the good boxes.
One provider corroborated this, citing a couple of previous trainees who completed all of the assessments, yet who were the ones who caused concerns clinically: …Yet they ticked all the boxes, so the assessments don’t pick up the failing doctors, really. They don’t pick up doctors who have an incorrect perception of themselves. [Trainees] choose [supervisors] who are going to give them a good result to give them their assessments.
Trainees volunteered the same information; the point of least resistance in completing assessments is simply to ask an amenable supervisor to sign your work off: …Rushing round speaking to friendly registrars who they know will probably sign them regardless. In all, four providers and several trainees mentioned this strategy, both groups recognising its shortcomings. Another provider predicted that the system would become more robust and more weak trainees would be identified early when supervisors developed more familiarity and faith in the system. One trainee believed that the lack of confidence in the assessment system was related to misgivings about the whole national Modernising Medical Careers agenda. There was an almost unanimous perception that many senior doctors viewed the Foundation Programme as less satisfactory than the old system.
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Final Draft – Confirmed at research sites 5/7/2008 At another site, however, the provider perception was that the system could differentiate since the performance of every trainee is discussed every 3 months in the Foundation Faculty Group.
11 11.1
Library and Information Services A cluster of issues arose around library and information services. One
librarian had not noticed much difference in usage between the old PRHO/SHO system and the Foundation Programme, excepting an impression that books rather than journal articles now make up the bulk of requests. This librarian felt that in the old system trainees wanted journal articles more often. This prompted a more systematic audit of usage in one of the sites. Out of the 260 most recently completed article request cards only 13 were from the Foundation Programme trainees. Eight of these could be fulfilled within the service using downloads, three were sourced from the health library network, and only one had to be obtained from the BMA library. The conclusion was that requests were declining more sharply than suspected.
One the other hand Knowledge and Information Services staff believed F2s used library services more, because investigation is part of the F2 curriculum, and F2s are starting to think about membership or specialty exams.
One site offers a session at the beginning of the F2 year on literature searching. The session was offered again half way through the year. But according to one librarian:
It was almost like a refresher, as if I was starting all over again. They obviously didn’t take it on board at that particular…time. They want things in context.
Only one library service contributed to F2 induction and neither contributed to F1 induction. All Library and Information Services staff interviewed favoured a more prominent contribution to induction in order to promote the most effective information finding strategies, and, at one site, the library staff wanted better contact with those providing the teaching. One provider suggested that Knowledge and Information Services might provide work-based learning resources in the near future.
11.2
At both sites librarians named basic text books, those most commonly used
in training such as the Oxford Handbook series, as being still commonly in use by trainees. This was corroborated by two trainees. One provider favoured teaching sessions for which trainees needed to do pre-reading in order to come prepared to
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Final Draft – Confirmed at research sites 5/7/2008 discuss the pros and cons in the management of a case. This strategy clearly stimulates library use.
11.3
Trainees cited pressure of time as the reason they made little use of the
library. Unanimously they used the internet as the main source of information. At both sites the reported preference of trainees was to use Google as a search engine principally for its ease of use, since passwords were not required. Two providers also routinely used this route while acknowledging that this was not a research route they would endorse or recommend to others. Library staff, however, expressed some concerns about this, since the authenticity and reliability of research sites accessed through Google could not be guaranteed.
Yes, they’re doing their own literature searches, but I’m not convinced they’re doing them well…I had a group of F1s and someone literally said, ‘if I want anything I just Google it.’ So I think there’s a huge step between what they’re doing and what they ought to be doing.
I would certainly say that it’s Pubmed rather than using the databases via Athens.
One provider was surprised to find trainees even accessing the specialty training application system (MTAS) through Google.
An F1 trainee seemed to corroborate the librarian’s concern about literature searching.
I don’t know if we have Athens or whatever usernames but we had to do a cardiology presentation and I could not get into any of the journals that I was looking up on the internet.
Two Supervisors felt strongly that it was important to promote the use of Athens passwords and PubMed in order to ensure the reliability of information for audits, presentations and general training. Providers and library staff frequently referred to ‘mindset’ as a barrier to proper computer access. The toil of using usernames and passwords for sites was frequently a turn off for busy consultants, especially in relation to filing assessment on computers.
12
Conclusions
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Final Draft – Confirmed at research sites 5/7/2008 12.1 There are clearly some mismatches between provider and trainee
perceptions of need during the Foundation Programme, notably around the balance of clinical and generic skills, and assessment. Davies (1997) cited in Taylor, points out individuals in training are rarely well placed to judge the efficacy of their course against the demands of future practice, the true nature of which they can only guess at. Her work on postgraduate social work training drew attention to the common feeling that there was never enough time to cover the necessary curriculum and that an extension to the time of training was desirable (1997:159).
She identified four key elements of postgraduate training:
• • • •
the ability to take the initiative; the ability to reflect critically on information; the ability to evaluate one’s own practice; the use of supervision (1997:160).
Her interviews with newly qualified social workers highlighted several common issues:
• • • • •
the pace of organizational change; lack of supervision; high caseloads; the necessity of paperwork and recording; induction.
There is a high correlation between these issues and ones encountered in the current study. For example, in five of the e-diaried or interview comments F1s reported difficulties in knowing when to take the initiative because of uncertainty over the boundaries of responsibility between the trainees and the more senior members of their firms.
12.2
A significant majority of trainees reported a common opinion among
Supervisors that the Foundation Programme is not as rigorous as the former PRHO and SHO system. This opinion results in a jaundiced approach to assessment and strengthens the case for engaging mid-career professionals (Eraut 1994) with the challenges and potentialities of the new system. Another provider favoured using a smaller cadre of the best educational supervisors, each responsible for around four trainees. :
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Final Draft – Confirmed at research sites 5/7/2008 A, they would be committed and b, because they’ve got three or four charges they’d be more inclined to follow them, they’ve got comparative analyses they can do – ‘I’ve got five here, these two are doing fantastically well, I’m a bit worried about this one, the other two are OK.’ That would be a better use of time and resource.
12.3
In an ideal world the new assessment system could be exploited as a key
catalyst for learning, rather than an addition to it. The contemporary concept of ‘assessment for learning’ (Black & William 1998), involves, fundamentally, the embedding of assessment as a means of learning rather than as a bureaucratic chore. Providers might profitably advocate an assessment for learning approach at the start of the Foundation Programme as a part of managing expectations.
13
Suggestions
The current study is designed to provide an account of the learner pathway during the Foundation Programme. It is emphatically not an evaluation of it, nor of practice in the two hospital sites. Nevertheless, it may be thought appropriate to consider these suggestions as the Foundation Programme is consolidated and refined. The following is, therefore, offered as embodying the implications for the KSS region, of this narrative about the learner pathway:
I. Review the assessment procedures and practices so each assessment format is exploited for its learning potential. II. Consider assembling a ‘starter pack’ of materials – Trust and hospital policies and processes – to dispatch to new trainees in order to prepare them with essential information for day one. III. Develop, acquire and exchange materials which teach clinical and generic skills simultaneously and seamlessly. IV. Consider delaying an induction programme until shortly after the peak holiday period in August. More providers would then be back from annual leave and able to take part, thus contributing to a more rounded experience. V. Seek opportunities to involve Library and Information Services in the Foundation Programme more fully. VI. Review on-call rotas for trainees balancing the EWTD against the reported trainee gains in confidence, independence and acceleration of expertise, mindful also of safe practices. VII. Engage with the widespread reported misgivings about the Foundation Programme, by addressing and reflecting on Supervisor attitudes to both the
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Final Draft – Confirmed at research sites 5/7/2008 old and the new system, and seeking to build advocacy for, and confidence in, the latter. VIII. Communicate and manage trainee expectations at induction, especially about assessment, responsibilities and duties, and the critical balance of clinical and generic skills.
References
(2005) The Rough Guide to the Foundation Programme, Rough Guides Ltd, London. Black, P. and Wiliam, D. (1998) Inside the Black Box, King's College, London. Boshuizen, H. P. A., Bromme, R. and Gruber, H. (Eds.) (2004) Professional Learning: Gaps and Transitions on the Way from Novice to Expert, Kluwer, Dordrecht. Foundation Programme Committee of the Academy of Medical Royal Colleges. (2004) Department of Health, London. Davies, M. (1984) In Social Work Today, pp. 12-17. Donaldson, L. (2002) Unfinished Business: Proposals for Reform of the senior House Officer Grade, Department of Health, London. Eraut, M. (1994) The Development of Professional Knowledge and Competence, Falmer Press, Falmer. Lave, J. and Wenger, E. (1991) Situated learning: Legitimate peripheral participation, Cambridge University Press, Cambridge. Radcliffe, C. and Lester, H. (2003) Perceived stress during undergraduate medical training: A qualitative study, Medical Education, 37, 32-38. Saljo, R. (1979) Learning about learning, Higher Education, 443-451. Shaw, P. and Wood, D. An evaluation of four foundation programme pilots in the Kent Surrey and Sussex Deanery, (2006) British Journal of Hospital Medicine, 67, 36-39. Taylor, I. (1997) Developing Learning in Professional Education: Partnerships for Practice, Open University Press, Buckingham. Wagenaar, A., Scherpbier, A. J. J. A., Boshuizen, H. P. A. and Van der Vleuten, C. P. M. (2003) The importance of active involvement in learning: A qualitative study on learning results and learning processes in different traineeships, Advances in Health Sciences Education, 8, 201-212.
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Final Draft – Confirmed at research sites 5/7/2008
Mapping the learner pathway – A report for Kent Surrey and Sussex Deanery for Postgraduate Medical and Dental Education – May 2007 Contents
1.1 Acknowledgements 1.2 Executive Summary 2 3 4 5 6 7 8 9 Introduction Methods The emphasis of the Foundation Programme. Induction The Pattern of Need on the Learner Pathway Confidence and competence Careers advice, guidance and information Clinical and Generic Professional skills
2 2 4 4 5 7 8 10 12 14 16 18 20 21 22
10 Assessment 11 Library and Information Services 12 Conclusions 13 Suggestions References
Author: David Wood
David Wood 2007 +44 (0)1869 321380 mob: 07903 671703 davidwoodconsultants@talktalk.net
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Final Draft – Confirmed at research sites 5/7/2008 1.1 Acknowledgements
The author wishes to acknowledge the generosity, co-operation, and cordiality of the staff at the two hospital sites during the data gathering for this evaluation. Particular thanks are due to the new doctors who participated in the study and the hospital staff who scheduled the programme of interviews at each site.
1.2
Executive Summary
KSS Deanery commissioned this study to determine whether common elements of a ‘learner pathway’ can be identified now that the Foundation Programme (FP) is becoming established. This study is designed to ask: a) what are the needs of Foundation Programme doctors, as learners, during the different stage(s) of the Foundation Programme; b) c) d) where they go to find appropriate information and resources; is existing provision appropriately matched to their needs; what makes a good learning experience?
The study was conducted in a six week period at two hospital sites. There were 17 semi-structured interviews with ‘providers,’ teaching and managing the FP and two focus group discussions at each site with a total of around 30 first year Foundation Programme (F1) trainees, of whom 23 volunteered to keep an email diary of their learning experiences for the six weeks between the first and second focus group interviews. In practice only a small minority emailed diary entries. Most trainees and providers believe that the core of the programme is the learning opportunities or ‘affordances’ which arise in daily clinical care. Despite this, less than a third of the trainees identified and recounted specific learning events during the six weeks. As the year progressed, trainees recognised and appreciated the contribution of the scheduled teaching sessions for all trainees more. Providers placed a high importance on formal induction to the FP, whilst trainees believed a clear introduction to Trust and hospital policies is their most pressing need during induction. The repetition of basic skills training at induction was a source of frustration to some trainees. Trainees need the most support during the first 4-6 weeks of the Programme and the first two weeks of each rotation. F2 needs are tightly focussed around career choices and the specialty training applications round (MTAS) as the second year progresses. Trainees experienced pressure to complete assessments and expressed concerns about the truncated period in which to do them in the final rotation of the year. At least seven trainees claimed that they gained considerable confidence when given, sometimes by default, increased independence and autonomy.
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Final Draft – Confirmed at research sites 5/7/2008 Trainee views about careers information and guidance were significantly affected by the introduction of MTAS during the period of the study. Most providers counselled against basic careers guidance, for example about form filling. Trainees almost unanimously valued careers sessions led by specialty registrars and consultants, and favoured careers sessions as early as possible during the FP. Providers highlighted trainee resistance to the teaching of generic skills and this was corroborated by the majority of trainees. Providers are beginning to favour the use of role play and other learning methods which integrate clinical and generic skills. There were widespread concerns about the assessment system. Trainees almost unanimously perceived it as ‘bolted on’ to real learning. At least one provider at each site was unconvinced that the assessment system differentiated adequately. However, another provider was confident that the system would work well once the FP was more established. This provider also advocated a smaller cadre of Educational Supervisors, selected on the basis of their advocacy of and confidence in the FP. Library and Information Services staff wished to make a more substantial contribution to the programme. Two of these staff interviewed pointed out that trainees made extensive use of Google for medical sources and so should be given more training in effective literature searching skills.
The study suggests that staff delivering the Foundation Programme in the KSS region could usefully exploit this account of the learner pathway by addressing one or more of eight suggested strategies involving:
I. II. III. IV. V. VI.
assessment; library and information services; assembling pre-course information; creating integrated materials for developing clinical and generic skills together; delaying induction; reviewing on-call rotas for trainees, balancing the European Working Time Directive (EWTD) and supervised practice against trainee gains in confidence, independence and the acceleration of expertise;
VII. VIII.
managing trainee expectations; managing change and misgivings about the FP.
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Final Draft – Confirmed at research sites 5/7/2008 2 Introduction
Following the Chief Medical Officer’s proposals in ‘Unfinished Business,’ (2002), the Foundation Programme for new doctors was introduced across the country in August 2005 when the first cohort of graduates from medical school entered the Programme.
Prior to this development the Kent, Surrey and Sussex (KSS) Deanery set up Foundation Programme pilots. The evaluation of these, (Dewhurst, Shaw & Wood: 2006) highlighted areas of emerging good practice. With the added experience of the first two cohorts going through the Foundation Programme, the study which follows is designed to address the following questions: a) what are the needs of Foundation Programme doctors, as learners, during the different stage(s) of the Foundation Programme; b) c) d) where do they go to find appropriate information and resources; is existing provision appropriately matched to their needs, what makes a good learning experience?
By collecting information about these issues, the study is designed to uncover a picture or map of the learner pathway through the Foundation Programme in two hospitals representative of the KSS region. It is hoped that the emerging picture will serve to inform the consolidation and refinement of the Foundation Programme in the KSS region.
In the text which follows, Foundation Programme doctors are referred to as ‘Trainees.’ The Foundation Programme lead staff - Medical Education Managers, Educational Supervisors and other staff providing the training - are referred to as the ‘providers.’
3
Methods
The study was conducted between March & May 2007 at two hospitals in the KSS region who agreed to take part. It therefore offered a sharply focussed insight into the development of learning for a group of year one trainees over a period of six weeks. Furthermore, the interviews with providers probed more general observations about the pattern of the learner pathway during the entire two years of the Foundation Programme.
The research was designed to provide multiple perspectives on the learning experience of the Foundation Programme. The research methods, therefore,
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Final Draft – Confirmed at research sites 5/7/2008 comprised semi-structured interviews with 17 providers including a Director of Medical Education, Medical Educational Managers, Foundation Programme leads, Education Supervisors, Clinical Supervisors and Knowledge Services Managers and their library colleagues, as well as Foundation Programme administrative staff.
3.1
At each site two focus group discussions took place with a representative
sample of year one (F1) trainees, one at the beginning and one at the end of the sixweek period. Each of the four discussions lasted around 45 minutes and, although trainees were sometimes ’bleeped’ to return urgently to wards, approximately 30 trainees from the 2 hospitals participated in the discussion at various points.
3.2
Following the first two focus group discussions, a total of 23 trainee
volunteers were asked to keep an email diary of the opportunities for learning they encountered during the following six weeks. Trainees were emailed a reminder about the e-diaries each week, but in practice only a small amount of data was collected by this method. Nevertheless, four of the volunteers emailed accounts of ‘critical incidents’ in their learning, all of which are described below.
3.3
The study also involved scrutinising documentation associated with the
Foundation Programme, both at a national level in documents such as the ‘Rough Guide to the Foundation Programme,’ (2005) and at each of the study sites in handbooks, curriculum documents and timetables.
4 4.1
The emphasis of the Foundation Programme Almost all of the individuals interviewed agreed that the principal objective of
the Foundation Programme is competency in clinical practice and in acute medical care. This aligns well with key objectives of the Programme as articulated by the Foundation Programme Committee (2004).
Trainees believed the programme essentially comprised the learning opportunities or ‘affordances’ which happen in daily practice:
It’s up to your seniors on the wards to be pro-active in your teaching. Luckily I’ve had one very good consultant.
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Final Draft – Confirmed at research sites 5/7/2008 The majority view was that learning is gained and consolidated by experience and attempts to provide a scheduled teaching programme are supplementary to the learning affordances gained from clinical work.
4.2
Each site provided a schedule of teaching sessions each week, as required
by the Foundation Programme curriculum. However, there were different approaches in the two different sites. For example, one site favoured shorter and more regular sessions; the other scheduled longer less frequent ones. The decision to stage longer sessions at one site was positively viewed by F2 trainees who did not like twice weekly lunchtime sessions. At one site the F1 teaching schedule centred on acute care, and involved key lecturers such as anaesthetists and surgeons to deliver the programme. Their F2 teaching schedule put more emphasis on generic skills, such as ethical issues, completing the most common forms and effective writing for a range of professional purposes. One provider expressed the view, that – on reflection – an integrated approach to teaching clinical and generic skills is preferable, and this approach was more often used at the other site. Another provider attached particular importance to longer teaching sessions believing that they make: Learning more of a workshop, more of a two-way discussion and not just sitting down listening to a lecture which is not the way to be teaching anybody.
In the first focus group interview, the majority of trainees felt that the teaching sessions made a very small contribution to their learning, serving as a distraction from the wards. However, by the second focus group interview, there was a significant shift to the view that the weekly scheduled sessions were becoming much more useful. Now we’re getting registrars and consultants coming in and speaking to us about their specialties and common things we’d see on the wards and their management…
4.3
A curious phenomenon is that, although the trainees unanimously agreed with
the proposition that nearly all learning happened through affordance and opportunity on the wards and in practice, fewer than ten critical learning incidents were recounted by the 30 trainees over the six weeks. Research by Wagenaar et al (2003) concluded that affordances are not recognised as real learning or exploited as such. This may explain the low number of learning events recounted by trainees in journals and in interviews. One provider had noticed this phenomenon:
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Final Draft – Confirmed at research sites 5/7/2008 [With] three hours a week protected teaching time the [trainees] only think they’re getting their learning then and not otherwise. And yet the learning on the job ought to be more fulfilling and more useful.
5 5.1
Induction One site has a full day induction for F1s and a full day for F2s. At the other
site there are 3 days of induction for F1s. There is also a trust-wide induction and, at the beginning of each rotation, induction related to each particular specialty.
One provider judged induction as a critically important element of the orientation exercise: Whatever we do, even if we give them a week for induction it’s not enough. It’s just a flavour. It’s not addressing the important issues.
The same provider believed, however, that the August start to the programme militated against effective induction: 40% of the workforce will be on leave! There can’t be any worse time to start. In [another country] they used to change in January and June, a much better time.
One trainee advocated a system where new trainees would shadow a more senior doctor for the first month of the first rotation, before having the hospital induction and taking more responsibility. Other trainees in this focus group liked this idea in
principle, but pointed out the cost implications and the need to take annual leave as well during the summer months.
5.2
About half of the trainees advocated a clear introduction to Trust and hospital
policies during induction. They believed that more information on the local approach to, for example, prescribing drugs such as Warfarin, expectations of on-call and the pain relief ladder, would have been very useful at induction. Trainees at the other site also claimed that their most pressing initial need was to find out about the Trust’s expectations of a trainee on call. One trainee advocated e-learning before induction as the best medium for communicating Trust and hospital policies, protocols and expectations, so that the induction itself could focus on practical skills. Others agreed saying that a new trainee is expected to follow trust policies on, for example, prescribing, on-call periods or how to respond to certain situations, from their first day without necessarily knowing the policies in question. Trainees primarily felt that a list of on-call responsibilities would have been useful during induction.
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5.3
The repetition of basic skills training at induction was a source of frustration to
some trainees and providers were aware of this: When they do canulation, some say ‘we did that at medical school.’ But we have F1s from different medical schools and different parts of the world. So they have to consolidate.
There were clear differences of opinion on this point in the interviews with trainees at one site. One trainee stressed the need for canulation training at induction while another expressed surprise that this had not been covered by all trainees at medical school. One trainee wrote an e-diary entry on the benefit of revising material learned as a student doctor: Today I was on the ward while the medical students were having their weekly bedside teaching session. I was able to listen in on the teaching and learnt a lot about presenting X-rays and examining patients. It was a good revision of things I knew well for finals but perhaps do not have the time to study now. It would be useful if F1s could have this kind of teaching. Being taught interactively on the wards seems much more relevant and interesting than lectures.
One of the sites had appointed a group of overseas trained doctors. The providers had learnt not to take certain competences for granted. For example, common practice in one EU country outside the UK is for nurses rather than doctors to take blood. Similarly, overseas trained doctors tended not to have practical experience of canulation. For this reason the hospital had introduced a two week pre-induction programme for trainees from overseas: To give them some flavour and so they know the system and so forth and it works to our advantage but it comes with some pressures: ie someone needs to assess the two weeks; we need people to be shadowed…
5.4
One trainee felt that more practical rather than theoretical skills should be
offered during induction, citing the baptism of fire she experienced when suddenly responsible for Warfarin dosing. A majority of the trainees at this site agreed, pointing out that this was the first time they had been responsible for decisions on a ward. You go to each ward and there is always a list of things to do and you just think ‘should I be doing this, should a senior colleague be doing it, should I leave this for the team for the next day?’ I know it’s up to us to prioritise but you do find yourself doing things which you perhaps shouldn’t be doing.
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6 6.1
The Pattern of Need on the Learner Pathway Virtually all providers and trainees independently identified the first four to six
weeks of the Programme and the first two weeks of each rotation as the most pressing periods of need for trainees. This matches research by Radcliffe & Lester (2003) which identifies the transition from student to apprentice doctor as the most frequently cited stressful period in medical training.
6.2
The pressure to submit Foundation Programme assessments dominated the
needs of some F2s, one provider reported. Virtually all providers said that the needs of F2 trainees become concentrated on career choices as the year progresses: Their priorities shift radically as the next rotation approaches and they think about how they will get the next job.
The most important need is how F2s can get into Specialty Training and how to make a successful application.
This may explain one provider’s view that neediness increases as the end of a rotation approaches.
Another provider emphasised the pressing need trainees felt by mid-May to complete assessment. According to this provider, the administrators needed to chase the majority of trainees for completed assessments and some had not even submitted the educational agreement from the start of the programme. The explanation was that trainees perceived paperwork as an irritating distraction from patient care. The provider, however, stressed that new doctors needed to get used to a professional environment in which paperwork was an indispensable part of records and professional practice, and this was echoed by one other provider: You can’t be a doctor if you’re not very good at paperwork.
A trainee anticipated the distinct pressure of starting the F2 year: In August we begin F2 and…for a lot of people prior to that we’ll have only had four months’ experience of medicine and yet I’ll be the medical SHO on call. I feel it’s a big jump. So much more responsibility comes with it.
6.3
Both trainees and providers pointed out that each year of the Foundation
Programme comprises, in effect, a nine and a half month programme of two four
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Final Draft – Confirmed at research sites 5/7/2008 month rotations and a final one for which assessments have to be completed within six weeks in order to be processed by the national system. One provider noted that some F1s were doing three month rotations so allowing the completion of three full sets of assessment and a rotation during which to consolidate. On the other hand, three month rotations allowed less time to develop competence and confidence. One provider suggested structuring the Programme as four sections of six-months, comprising 18 months acquiring competences in medicine, surgery, GP and A&E and sub-specialties within them as well as getting assessments signed off, and devoting the last six months to career planning: …Instead of what is currently happening, this enormous pressure at the end. They’ve got to move, they’ve got to get signed up, they’ve got to get a job, they’ve got to do an audit presentation and so forth…
6.4
One provider drew attention to the needs of the trainees who are most
focused, driven and well-organised: Those who are doing quite well by the system but are still ‘system bashing.’
Trainees who are: Very stressed about ‘am I going to get on the surgical training programme and is the job going to be as I expect in 5 years time’... so their stresses are different depending on the kind of personality they are.
Another distinctive view was that trainees’ most pressing need at the beginning of the FP is to adjust to professional demands: Timekeeping, the fact that they’re working, time management are all things they need right from the word go. They are more focused on knowledge rather than professional development and the two go hand in hand. We shouldn’t need [a dress code policy] For this interviewee, this professionalism might take a few months to develop in trainees though the most mature might develop it in two weeks or so. This view aligns well with Boshuizen et al (2004) who cite six different studies in which new doctors report difficulty prioritising, and lack of experience in organisational skills.
7 7.1
Confidence and competence A provider expressed concerns that the European Working Time Directive
had resulted in an unintended overprotection of trainees, ‘wrapping them in cotton
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Final Draft – Confirmed at research sites 5/7/2008 wool.’ This provider felt that the Foundation Programme should avoid spoon feeding and instead make challenging demands of the new recruits: We have finally started our [trainees] to be on call at night and they…were a bit upset about it because they had to do it but after they did a week of nights I’ve had feedback saying ‘that was so good because I have increased in confidence.’ Trainees at one hospital regretted the fact that they were not given the opportunity to work nights during their F1 year, since so much experience could be gained from working night shifts.
Independently, trainees made several comments about this issue. Seven comments, volunteered in interviews and e-diary entries, were about autonomy and arm’s length supervision resulting in an accelerated growth of confidence and expertise, especially when circumstances forced the trainee to take more responsibility.
I recently worked a week of nights with a [Senior House Officer] who has a reputation for being unsupportive to juniors. I anticipated learning next to nothing. In reality, although I rarely saw my SHO (and when I did his advice was not helpful) I learnt more in that week than any other… This was because I was faced with scenarios that needed my intervention. My choice was to do nothing and wait for the SHO, or get on with it and hope that what I did would work. It turned out that much of what I was doing was right. The things I didn’t know, I would quickly look up. The week boosted my confidence no end. I think this illustrates that doing and seeing is the best way to learn.
7.2
This view was tempered by one trainee who pointed out that medicine is not a
profession where it is often appropriate to learn by trial and error, but by observing practice. Nevertheless, a small group of trainees described a set of problems involving staffing in a particular firm. Whilst they expressed dismay about the lack of supervision and guidance they had received as a result of the difficulties, they were unanimous in concluding that this had been a useful learning experience. These trainees had needed to take on more responsibility and this had boosted their confidence and accelerated their skill acquisition.
Conversely, one trainee recognised the dangers of abrogating responsibility when under close supervision: When you’ve got a senior by your side you lose the capability to think…you become lazy, mentally, and when you haven’t got a senior there you have to think.
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Final Draft – Confirmed at research sites 5/7/2008 One provider suggested that GP rotations strike an ideal balance between independence and supervision. Because of the structure of GP work, it was claimed, there is more time for 1:1 supervision as well as mentoring and pastoral support within a context in which the trainee regularly runs clinics independently.
Providers noted a pattern of increased confidence towards the end of a rotation and agreed that need diminished towards the end of four month rotations. Two providers and several trainees pointed out that four month rotations are not long enough for trainees to consolidate the new skills they have learnt before they move on. One cited a case in paediatrics where a trainee had raised concerns - correctly - about a case of child abuse. This had given the trainee notable new levels of confidence and self-esteem.
8 8.1
Careers advice, guidance and information It should be emphasised that attitudes to careers were significantly affected
by the precise period during which the study was conducted. The introduction of competitive entry into specialties after the FP radically changed the expectations of new doctors. The Department of Health’s difficulties introducing the specialty training application process (MTAS) led to jaundiced views of careers guidance and information whilst conducting the research. This very point was raised and acknowledged by two trainees during the second focus groups discussions, and by three providers.
8.2
Nonetheless, KSS Deanery staff recognised that careers information and
guidance had become an increasing priority for them since the late 1990s. The Deanery now stages a half-day training course for Educational and Clinical Supervisors on providing careers information, guidance and advice as well as a resource book. At one site two sessions are provided for F2s and one for F1s. One site had a careers afternoon for all Foundation Programme trainees, so each year could harness the skills and knowledge of the other. In addition careers guidance plays a part in the three meetings between Educational Supervisor and trainee each year, and providers expect to give regular informal advice on a one to one basis.
Providers expressed some frustration about their access to MTAS information during this period:
We have spent a lot of time on this; probably more than we expected.
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Final Draft – Confirmed at research sites 5/7/2008
I can’t tell people how to apply if I don’t know what they are looking for in the application.
If they tell me the chance of X person getting into a specialty is 1000 to 1, I’ll advise them not to apply. If someone, for example, is going into xx specialty, what is the chance of them being interviewed? For example, if you look at KSS, a large area, only 30 trainees are to be appointed [in xx specialty].
Shortly after period during which the research was conducted, however, this sort of demographic information became available
8.3
Two interviewees expressed concerns about the low level of some careers
guidance. One provider, whilst noting trainee concerns about application processes, felt that to provide basic advice was unnecessary: I think they are beginning to stand on their own two feet and I’m not sure you need to tell them how to fill a form in.
A further provider believed that informed decision making should be the prime objective of careers sessions: You’ve got to think about the lifestyle that this career choice would involve against that career choice and I think that’s much more important. I don’t think people need four sessions to fill out an MTAS form when they’re fairly self-explanatory.
A trainee at one site was also disappointed about the level of a careers session. We had to cut and paste adjectives and put them into boxes.
However, another provider cited anecdotal responses from F2s that such baseline guidance was improving their application skills and chances of success in competition for specialty places.
There was a consensus that careers information and guidance was useful in the dedicated teaching sessions as early as possible. What you do in these 2 years affects your chances of getting on to what you want to do in the future.
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Final Draft – Confirmed at research sites 5/7/2008 The KSS Deanery was introducing such work at earlier stages during the study and also supported the introduction of more careers work during undergraduate courses.
Trainees almost unanimously favoured careers sessions in which senior staff in various specialties, ‘such as surgeons and anaesthetists’ talked about what they did and the routes and decisions they had taken. Two providers agreed and reported a trend to schedule more of this type of session in the near future.
9 9.1
Clinical and Generic Professional skills We have to balance and we try our best to balance between generic and
clinical care.
Interviewees often commented on the tension in the Foundation Programme between clinical and ‘generic’ skills. The latter phrase denotes the broad range of professional tasks outside clinical processes and procedures. It includes functions like communication with families and spouses, completing death certificates, medical ethics and other issues. The fact that this broad range of tasks are all grouped under the title ‘skills’ in MMC terminology and everyday discourse may imply that this area of professional development warrants more scrutiny and thought.
Most providers believed that trainees are resistant to generic skills teaching: Whenever you do that you get them asking, ‘why are we doing that? We want more clinical work. We want to be working in the ward.’ But when they get to that level they will need [generic skills].
A lot of them say I don’t need that, what are you teaching that for?
That’s where needs conflict because we are trying to give them a generic programme where they say tell me what I need to know today…
Providers gave specific examples of this tension: For example: filling in a death certificate. It’s very important. Unfortunately they will have to do that. And we get reports that people are not filling them in properly. So we have to go back and see that they have to do it. Have to learn how to do it.
At another site a provider raised the same topic.
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Final Draft – Confirmed at research sites 5/7/2008 We’ve had a circular here asking if we can include death certificates earlier on. The problem is you need to include…the unconscious patient, everyone wants to be taught about diabetes, they want to be taught about managing hypertension on the wards, pre-op assessment and they all want to be taught that in the first week! And if you are on a diabetic firm you don’t need a lecture on diabetes whereas on surgical you do need that lecture on diabetes because you’ve got a pre-op patient you’ve got to prepare for theatre and get that diabetes sorted out.
One provider drew attention to the internal contradictions he faced in trainee feedback about generic skills. They love practical things like suturing. [And yet when] I did a session for ethics and law and they loved it, but often they say [beforehand] ‘we don’t need that.’
9.2
To illustrate the complexity of generic skills development, another provider
described how she conducts interviews with families and instructs trainees to stay with the nurse and the family after she leaves because of the change in the dynamics this precipitates. In her view, the family adopt a more informal approach and ask more questions without the presence of the consultant, and this illustrates the potential for the doctor to be unconsciously intimidating. This provider believes it is important for the trainee to observe and reflect on the effect doctors have on patients and their families, observing: Communication skills with a family is much harder than doing a canula.
This provider cited a case in which a family had wrongly blamed an F2 trainee for a clinical decision the trainee hadn’t herself made. This had been a unique situation which challenged her approach to professional conduct.
An F1 trainee emailed an account of a similarly challenging situation:
I was called to see a patient who had xxx – this patient had been refusing any medical intervention. The patient’s wife confronted me in a very aggressive manner, demanding to know why her husband has been put through all of these investigations while in hospital and asking me, “Why can’t we just leave him alone and let him go home?” I was completely astounded by her manner and demands at first. Then I tried to explain to her that I was the doctor on call, therefore this was my first encounter with this patient, and I was called to see him because the nurses were concerned about his condition. The wife persisted in her tearful accusations. I then very firmly
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Final Draft – Confirmed at research sites 5/7/2008 told her that she must address such concerns with the team responsible for her husband’s care. In the end, she seemed to understand my point and decided to speak to the team the following day. The experience was difficult for me as I am a very gentle person by nature, but at the same time showed me that I need to take charge in such situations and that when need be, I can actually do it.
9.3
One provider advocated an integrated approach::
It’s very hard for a learner to know what they need to learn. They have a perception of what they need to learn. But they have to know about other things and it’s difficult to introduce it without them feeling very negative about it. [But] if it is part of an afternoon about trauma…you can bring in talking to somebody who’s a distressed relative. So you’re not learning communication in isolation to everything else.
It’s just a question of re-badging, re-packaging it more so that they will be learning about the clinical situation and applying these generic skills in practical ways.
Another provider advocated role-play as a means of integrating generic and clinical skills in the Foundation Programme. The use of volunteers (PALS) as patients allowed trainees to practise case-based discussions, and to see the importance of some generic skills, such as talking to relatives and spouses. It also allowed the trainees to bring their own experiences to the case. Unprompted, F1 Trainees mentioned that this learning method was a valuable one. Another provider expressed an aspiration to begin to use this, although his hospital was not currently using it.
9.4
Lave & Wenger (1991) advocate this sort of approach as an authentic
variation on their situated learning theory, designed to bridge the theory-practice divide. Säljö’s (1979) research into levels of adult learning led to his model of five levels of learner maturity. The above practice aligns well with Säljö’s levels four and five in which the learner makes sense or abstracts meaning by relating different elements of subject matter to the real world. We have to go with the curriculum; to make sure they have a balance. Generic teaching has to be there. They [trainees] are more likely to ask for more acute rather than generic teaching.
All the above suggests that an important development of the Foundation Programme will be to manage the expectations of the trainees. Trainees are more likely to
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Final Draft – Confirmed at research sites 5/7/2008 perceive themselves as journeymen and women perfecting a set of skills, rather than recognising the key contribution of generic skills to their development.
10 10.1
Assessment Nearly every trainee believed that the national assessment system for the
Foundation Programme is an extraneous process, which adds nothing to the learning experience and constitutes an irrelevant burden. The assessments we do are farcical and contrived… Its just a hoop to jump through. This attitude is enacted in the difficulty in gathering in assessments which administrators reported.
On the other hand one provider believed that F1s enter the programme with a conscientious approach to completing assessments and: As time goes on they become less bothered by it. Because nobody didn’t get signed off last year they assume that if they don’t do them it will all be fine. It’s a paper exercise, I don’t think it’s taken terribly seriously, it’s very labour intensive…they should do in a few in each and every rotation but they don’t, they save them up to the end so it makes it a waste of time really. If the system is going to continue we need to have the teeth to say you...will have to start your F1 year again.
One or two trainees had a different perspective: I learnt the most I ever learnt clerking someone in MAU and then we sat down and presented it to a registrar and he talked me though it. And it happened to be a [CaseBased Discussion] but I didn’t go to them and say can we have this as a CBD and she taught me loads and it took about 15 minutes.
When it’s done properly it probably is quite beneficial but otherwise it’s so hard to get that time.
Another trainee seemed to see the irony of an unpopular assessment system which, potentially, could be seamlessly integrated into learning:
The silly thing is you do it every day on the ward round, you discuss cases…you see people. You have to pin people down for a silly piece of paper that doesn’t actually count for anything.
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Final Draft – Confirmed at research sites 5/7/2008 Trainees favoured Case-Based Discussion (CBD) as the most relevant and useful form of assessment but claimed, as did providers, that the electronic submission of CBD assessments is inconvenient. For trainees it was difficult enough to interrupt a busy consultant schedule to do the assessment and the electronic submission system and password access compounded the barriers to completion. One or two trainees and providers pointed out that staff in other medical professions could also sign off assessments.
10.2
Two providers expressed doubts about whether the system could differentiate
effectively between trainees. Trainees were aware of this too:
If you get a bad form, you don’t have to submit that form…you’d submit your six best assessments. If someone’s not very good they could probably find six people that will just tick away at the good boxes.
One provider corroborated this, citing a couple of previous trainees who completed all of the assessments, yet who were the ones who caused concerns clinically: …Yet they ticked all the boxes, so the assessments don’t pick up the failing doctors, really. They don’t pick up doctors who have an incorrect perception of themselves. [Trainees] choose [supervisors] who are going to give them a good result to give them their assessments.
Trainees volunteered the same information; the point of least resistance in completing assessments is simply to ask an amenable supervisor to sign your work off: …Rushing round speaking to friendly registrars who they know will probably sign them regardless. In all, four providers and several trainees mentioned this strategy, both groups recognising its shortcomings. Another provider predicted that the system would become more robust and more weak trainees would be identified early when supervisors developed more familiarity and faith in the system. One trainee believed that the lack of confidence in the assessment system was related to misgivings about the whole national Modernising Medical Careers agenda. There was an almost unanimous perception that many senior doctors viewed the Foundation Programme as less satisfactory than the old system.
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Final Draft – Confirmed at research sites 5/7/2008 At another site, however, the provider perception was that the system could differentiate since the performance of every trainee is discussed every 3 months in the Foundation Faculty Group.
11 11.1
Library and Information Services A cluster of issues arose around library and information services. One
librarian had not noticed much difference in usage between the old PRHO/SHO system and the Foundation Programme, excepting an impression that books rather than journal articles now make up the bulk of requests. This librarian felt that in the old system trainees wanted journal articles more often. This prompted a more systematic audit of usage in one of the sites. Out of the 260 most recently completed article request cards only 13 were from the Foundation Programme trainees. Eight of these could be fulfilled within the service using downloads, three were sourced from the health library network, and only one had to be obtained from the BMA library. The conclusion was that requests were declining more sharply than suspected.
One the other hand Knowledge and Information Services staff believed F2s used library services more, because investigation is part of the F2 curriculum, and F2s are starting to think about membership or specialty exams.
One site offers a session at the beginning of the F2 year on literature searching. The session was offered again half way through the year. But according to one librarian:
It was almost like a refresher, as if I was starting all over again. They obviously didn’t take it on board at that particular…time. They want things in context.
Only one library service contributed to F2 induction and neither contributed to F1 induction. All Library and Information Services staff interviewed favoured a more prominent contribution to induction in order to promote the most effective information finding strategies, and, at one site, the library staff wanted better contact with those providing the teaching. One provider suggested that Knowledge and Information Services might provide work-based learning resources in the near future.
11.2
At both sites librarians named basic text books, those most commonly used
in training such as the Oxford Handbook series, as being still commonly in use by trainees. This was corroborated by two trainees. One provider favoured teaching sessions for which trainees needed to do pre-reading in order to come prepared to
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Final Draft – Confirmed at research sites 5/7/2008 discuss the pros and cons in the management of a case. This strategy clearly stimulates library use.
11.3
Trainees cited pressure of time as the reason they made little use of the
library. Unanimously they used the internet as the main source of information. At both sites the reported preference of trainees was to use Google as a search engine principally for its ease of use, since passwords were not required. Two providers also routinely used this route while acknowledging that this was not a research route they would endorse or recommend to others. Library staff, however, expressed some concerns about this, since the authenticity and reliability of research sites accessed through Google could not be guaranteed.
Yes, they’re doing their own literature searches, but I’m not convinced they’re doing them well…I had a group of F1s and someone literally said, ‘if I want anything I just Google it.’ So I think there’s a huge step between what they’re doing and what they ought to be doing.
I would certainly say that it’s Pubmed rather than using the databases via Athens.
One provider was surprised to find trainees even accessing the specialty training application system (MTAS) through Google.
An F1 trainee seemed to corroborate the librarian’s concern about literature searching.
I don’t know if we have Athens or whatever usernames but we had to do a cardiology presentation and I could not get into any of the journals that I was looking up on the internet.
Two Supervisors felt strongly that it was important to promote the use of Athens passwords and PubMed in order to ensure the reliability of information for audits, presentations and general training. Providers and library staff frequently referred to ‘mindset’ as a barrier to proper computer access. The toil of using usernames and passwords for sites was frequently a turn off for busy consultants, especially in relation to filing assessment on computers.
12
Conclusions
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Final Draft – Confirmed at research sites 5/7/2008 12.1 There are clearly some mismatches between provider and trainee
perceptions of need during the Foundation Programme, notably around the balance of clinical and generic skills, and assessment. Davies (1997) cited in Taylor, points out individuals in training are rarely well placed to judge the efficacy of their course against the demands of future practice, the true nature of which they can only guess at. Her work on postgraduate social work training drew attention to the common feeling that there was never enough time to cover the necessary curriculum and that an extension to the time of training was desirable (1997:159).
She identified four key elements of postgraduate training:
• • • •
the ability to take the initiative; the ability to reflect critically on information; the ability to evaluate one’s own practice; the use of supervision (1997:160).
Her interviews with newly qualified social workers highlighted several common issues:
• • • • •
the pace of organizational change; lack of supervision; high caseloads; the necessity of paperwork and recording; induction.
There is a high correlation between these issues and ones encountered in the current study. For example, in five of the e-diaried or interview comments F1s reported difficulties in knowing when to take the initiative because of uncertainty over the boundaries of responsibility between the trainees and the more senior members of their firms.
12.2
A significant majority of trainees reported a common opinion among
Supervisors that the Foundation Programme is not as rigorous as the former PRHO and SHO system. This opinion results in a jaundiced approach to assessment and strengthens the case for engaging mid-career professionals (Eraut 1994) with the challenges and potentialities of the new system. Another provider favoured using a smaller cadre of the best educational supervisors, each responsible for around four trainees. :
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Final Draft – Confirmed at research sites 5/7/2008 A, they would be committed and b, because they’ve got three or four charges they’d be more inclined to follow them, they’ve got comparative analyses they can do – ‘I’ve got five here, these two are doing fantastically well, I’m a bit worried about this one, the other two are OK.’ That would be a better use of time and resource.
12.3
In an ideal world the new assessment system could be exploited as a key
catalyst for learning, rather than an addition to it. The contemporary concept of ‘assessment for learning’ (Black & William 1998), involves, fundamentally, the embedding of assessment as a means of learning rather than as a bureaucratic chore. Providers might profitably advocate an assessment for learning approach at the start of the Foundation Programme as a part of managing expectations.
13
Suggestions
The current study is designed to provide an account of the learner pathway during the Foundation Programme. It is emphatically not an evaluation of it, nor of practice in the two hospital sites. Nevertheless, it may be thought appropriate to consider these suggestions as the Foundation Programme is consolidated and refined. The following is, therefore, offered as embodying the implications for the KSS region, of this narrative about the learner pathway:
I. Review the assessment procedures and practices so each assessment format is exploited for its learning potential. II. Consider assembling a ‘starter pack’ of materials – Trust and hospital policies and processes – to dispatch to new trainees in order to prepare them with essential information for day one. III. Develop, acquire and exchange materials which teach clinical and generic skills simultaneously and seamlessly. IV. Consider delaying an induction programme until shortly after the peak holiday period in August. More providers would then be back from annual leave and able to take part, thus contributing to a more rounded experience. V. Seek opportunities to involve Library and Information Services in the Foundation Programme more fully. VI. Review on-call rotas for trainees balancing the EWTD against the reported trainee gains in confidence, independence and acceleration of expertise, mindful also of safe practices. VII. Engage with the widespread reported misgivings about the Foundation Programme, by addressing and reflecting on Supervisor attitudes to both the
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Final Draft – Confirmed at research sites 5/7/2008 old and the new system, and seeking to build advocacy for, and confidence in, the latter. VIII. Communicate and manage trainee expectations at induction, especially about assessment, responsibilities and duties, and the critical balance of clinical and generic skills.
References
(2005) The Rough Guide to the Foundation Programme, Rough Guides Ltd, London. Black, P. and Wiliam, D. (1998) Inside the Black Box, King's College, London. Boshuizen, H. P. A., Bromme, R. and Gruber, H. (Eds.) (2004) Professional Learning: Gaps and Transitions on the Way from Novice to Expert, Kluwer, Dordrecht. Foundation Programme Committee of the Academy of Medical Royal Colleges. (2004) Department of Health, London. Davies, M. (1984) In Social Work Today, pp. 12-17. Donaldson, L. (2002) Unfinished Business: Proposals for Reform of the senior House Officer Grade, Department of Health, London. Eraut, M. (1994) The Development of Professional Knowledge and Competence, Falmer Press, Falmer. Lave, J. and Wenger, E. (1991) Situated learning: Legitimate peripheral participation, Cambridge University Press, Cambridge. Radcliffe, C. and Lester, H. (2003) Perceived stress during undergraduate medical training: A qualitative study, Medical Education, 37, 32-38. Saljo, R. (1979) Learning about learning, Higher Education, 443-451. Shaw, P. and Wood, D. An evaluation of four foundation programme pilots in the Kent Surrey and Sussex Deanery, (2006) British Journal of Hospital Medicine, 67, 36-39. Taylor, I. (1997) Developing Learning in Professional Education: Partnerships for Practice, Open University Press, Buckingham. Wagenaar, A., Scherpbier, A. J. J. A., Boshuizen, H. P. A. and Van der Vleuten, C. P. M. (2003) The importance of active involvement in learning: A qualitative study on learning results and learning processes in different traineeships, Advances in Health Sciences Education, 8, 201-212.
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