Have restricted working hours reduced junior doctors' experience of fatigue? A focus group and telephone interview study.

OBJECTIVE: To explore the effects of the UK Working Time Regulations (WTR) on trainee doctors' experience of fatigue. DESIGN: Qualitative study involving focus groups and telephone interviews, conducted in Spring 2012 with doctors purposively selected from Foundation and specialty training. Final compliance with a 48 h/week limit had been required for trainee doctors since August 2009. Framework analysis of data. SETTING: 9 deaneries in all four UK nations; secondary care. PARTICIPANTS: 82 doctors: 53 Foundation trainees and 29 specialty trainees. 36 participants were male and 46 female. Specialty trainees were from a wide range of medical and surgical specialties, and psychiatry. RESULTS: Implementation of the WTR, while acknowledged as an improvement to the earlier situation of prolonged excessive hours, has not wholly overcome experience of long working hours and fatigue. Fatigue did not only arise from the hours that were scheduled, but also from an unpredictable mixture of shifts, work intensity (which often resulted in educational tasks being taken home) and inadequate rest. Fatigue was also caused by trainees working beyond their scheduled hours, for reasons such as task completion, accessing additional educational opportunities beyond scheduled hours and staffing shortages. There were also organisational, professional and cultural drivers, such as a sense of responsibility to patients and colleagues and the expectations of seniors. Fatigue was perceived to affect efficiency of skills and judgement, mood and learning capacity. CONCLUSIONS: Long-term risks of continued stress and fatigue, for doctors and for the effective delivery of a healthcare service, should not be ignored. Current monitoring processes do not reflect doctors' true working patterns. The effectiveness of the WTR cannot be considered in isolation from the culture and context of the workplace. On-going attention needs to be paid to broader cultural issues, including the relationship between trainees and seniors.

Professionalism education should reflect reality: findings from three health professions.

CONTEXT: Despite a growing and influential literature, 'professionalism' remains conceptually unclear. A recent review identified three discourses of professionalism in the literature: the individual; the interpersonal, and the societal-institutional. Although all have credibility and empirical support, there are tensions among them. OBJECTIVES: This paper considers how these discourses reflect the views of professionalism as they are expressed by students and educator-practitioners in three health care professions, and their implications for education. METHODS: Twenty focus groups were carried out with 112 participants, comprising trainee and educator paramedics, occupational therapists and podiatrists. The focus group discussions addressed participants' definitions of professionalism, the sources of their perceptions, examples of professional and unprofessional behaviour, and the point at which participants felt one became 'a professional'. RESULTS: Analysis found views of professionalism were complex, and varied within and between the professional groups. Participants' descriptions of professionalism related to the three discourses. Individual references were to beliefs or fundamental values formed early in life, and to professional identity, with professionalism as an aspect of the self. Interpersonal references indicated the definition of 'professional' behaviour is dependent on contextual factors, with the meta-skill of selecting an appropriate approach being fundamental. Societal-institutional references related to societal expectations, to organisational cultures (including management support), and to local work-group norms. These different views overlapped and combined in different ways, creating a complex picture of professionalism as something highly individual, but constrained or enabled by context. Professionalism is grown, not made. CONCLUSIONS: The conceptual complexity identified in the findings suggests that the use of 'professionalism' as a descriptor, despite its vernacular accessibility, may be problematic in educational applications in which greater precision is necessary. It may be better to assume that 'professionalism' as a discrete construct does not exist per se, and to focus instead on specific skills, including the ability to identify appropriate behaviour, and the organisational requirements necessary to support those skills.

Cultural dimensions in the transition of overseas medical graduates to the UK workplace.

BACKGROUND: Historically, overseas-qualified doctors have been essential for meeting service needs in the UK National Health Service (NHS). However, these doctors encounter many cultural differences, in relation to training, the healthcare system and the doctor-patient relationship and training. AIM: To examine whether Hofstede's cultural model may help us understand the changes doctors from other countries experience on coming to work in the UK, and to identify implications for supervisors and clinical teams. METHOD: Telephone interviews were conducted with overseas medical graduates before starting work as a Foundation Year One (F1) doctor, followed up after four months and 12 months; and with educational supervisors. Data were analysed using a confirmatory thematic approach. RESULTS: Sixty-four initial interviews were conducted with overseas doctors, 56 after four months, and 32 after 12 months. Twelve interviews were conducted with educational supervisors. The changes doctors experienced related particularly to Hofstede's dimensions of power distance (e.g. in relation to workplace hierarchies and inter-professional relationships), uncertainty avoidance (e.g. regarding ways of interacting) and individualism-collectivism (e.g., regarding doctor-patient/family relationship; assertiveness of individuals). CONCLUSION: Hofstede's cultural dimensions may help us understand the adaptations some doctors have to make in adjusting to working in the UK NHS. This may promote awareness and understanding and greater 'cultural competence' amongst those working with them or supervising them in their training.

Newly qualified doctors' perceptions of informal learning from nurses: implications for interprofessional education and practice.

Newly qualified doctors spend much of their time with nurses, but little research has considered informal learning during that formative contact. This article reports findings from a multiple case study that explored what newly qualified doctors felt they learned from nurses in the workplace. Analysis of interviews conducted with UK doctors in their first year of practice identified four overarching themes: attitudes towards working with nurses, learning about roles, professional hierarchies and learning skills. Informal learning was found to contribute to the newly qualified doctors' knowledge of their own and others' roles. A dynamic hierarchy was identified: one in which a "pragmatic hierarchy" recognising nurses' expertise was superseded by a "normative structural hierarchy" that reinforced the notion of medical dominance. Alongside the implicit learning of roles, nurses contributed to the explicit learning of skills and captured doctors' errors, with implications for patient safety. The findings are discussed in relation to professional socialisation. Issues of power between the professions are also considered. It is concluded that increasing both medical and nursing professions' awareness of informal workplace learning may improve the efficiency of education in restricted working hours. A culture in which informal learning is embedded may also have benefits for patient safety.

Perceptions of UK medical graduates' preparedness for practice: a multi-centre qualitative study reflecting the importance of learning on the job.

BACKGROUND: There is evidence that graduates of different medical schools vary in their preparedness for their first post. In 2003 Goldacre et al. reported that over 40% of UK medical graduates did not feel prepared and found large differences between graduates of different schools. A follow-up survey showed that levels of preparedness had increased yet there was still wide variation. This study aimed to examine whether medical graduates from three diverse UK medical schools were prepared for practice. METHODS: This was a qualitative study using a constructivist grounded theory approach. Prospective and cross-sectional data were collected from the three medical schools.A sample of 60 medical graduates (20 from each school) was targeted. They were interviewed three times: at the end of medical school (n = 65) and after four (n = 55) and 12 months (n = 46) as a Year 1 Foundation Programme doctor. Triangulated data were collected from clinicians via interviews across the three sites (n = 92). In addition three focus groups were conducted with senior clinicians who assess learning portfolios. The focus was on identifying areas of preparedness for practice and any areas of lack of preparedness. RESULTS: Although selected for being diverse, we did not find substantial differences between the schools. The same themes were identified at each site. Junior doctors felt prepared in terms of communication skills, clinical and practical skills and team working. They felt less prepared for areas of practice that are based on experiential learning in clinical practice: ward work, being on call, management of acute clinical situations, prescribing, clinical prioritisation and time management and dealing with paperwork. CONCLUSIONS: Our data highlighted the importance of students learning on the job, having a role in the team in supervised practice to enable them to learn about the duties and responsibilities of a new doctor in advance of starting work.

Does specialty training prepare doctors for senior roles? A questionnaire study of new UK consultants.

AIM: To measure new consultants' perceptions of their preparedness for different clinical and non-clinical aspects of the role of consultant. DESIGN: A cross-specialty questionnaire was developed and validated, containing items asking how well specialty training had prepared respondents for the role of consultant in a number of clinical and non-clinical areas. Responses were on a five-point Likert scale with a 'Not relevant/no opinion' box, and one free text section. Analysis was carried out on 10 scales derived from the questionnaire items through exploratory factor analysis. PARTICIPANTS: Consultants who had completed their specialty training in the north of England between 2004 and 2009 and had held a substantive consultant post in the region for <5 years were sent questionnaires in late 2009. RESULTS: The effective response rate was 70.6% (211/299). Ten factors reflecting areas including clinical skills, communication skills, team and resource management were identified. Overall, higher scores were observed on factors relating to 'providing care for individual patients' rather than 'having responsibility for the system of care'. The lowest scoring factors related to resource management and supervision, with mean scores falling below the scale midpoint. There were no significant differences between specialty groups, or on any demographic variables. CONCLUSIONS: A questionnaire to measure new consultants' perceptions of how well their specialty training had prepared them for practice was developed and validated. Findings were similar across specialties, suggesting that training programmes in all areas need to integrate higher-level management skills into their curricula, alongside the development of clinical expertise.

Preparedness for practice: the perceptions of medical graduates and clinical teams.

BACKGROUND: Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school. AIMS: To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members. METHOD: An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts. RESULTS: The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites. CONCLUSIONS: New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.

Junior doctors prescribing: enhancing their learning in practice.

AIM: This aim of this paper was to explore new doctors' preparedness for prescribing. METHODS: This was a multiple methods study including face-to-face and telephone interviews, questionnaires and secondary data from a safe prescribing assessment (n= 284). Three medical schools with differing curricula and cohorts were included: Newcastle (systems-based, integrated curriculum); Warwick (graduate entry) and Glasgow [problem-based learning (PBL)], with graduates entering F1 in their local deanery. The primary sample consisted of final year medical students, stratified by academic quartile (n= 65) from each of the three UK medical schools. In addition an anonymous cohort questionnaire was distributed at each site (n= 480), triangulating interviews were conducted with 92 clinicians and questionnaire data were collected from 80 clinicians who had worked with F1s. RESULTS: Data from the primary sample and cohort data highlighted that graduates entering F1 felt under-prepared for prescribing. However there was improvement over the F1 year through practical experience and support. Triangulating data reinforced the primary sample findings. Participants reported that learning in an applied setting would be helpful and increase confidence in prescribing. No clear differences were found in preparedness to prescribe between graduates of the three medical schools. CONCLUSION: The results form part of a larger study 'Are medical graduates fully prepared for practice?'. Prescribing was found to be the weakest area of practice in all sources of data. There is a need for more applied learning to develop skill-based, applied aspects of prescribing which would help to improve preparedness for prescribing.

Does questionnaire-based patient feedback reflect the important qualities of clinical consultations? Context, benefits and risks.

OBJECTIVE: To explore perceptions of clinical consultations and how they relate to questionnaire-based patient feedback. METHODS: Telephone interviews with 35 junior doctors and 40 general practice patients who had used the Doctors' Interpersonal Skills Questionnaire (DISQ). RESULTS: Doctors and patients had similar views of 'good consultations' as relying on doctors' listening and explaining skills. Preferences for a consultation style focused on an outcome or on the doctor-patient relationship may be independent of informational and/or affective consultation content. Respondents felt the important consultation elements were similar in different contexts, and so DISQ feedback would be useful in different settings. Benefits of feedback were identified in the form of patient empowerment and doctors' learning. Risks were identified in the inappropriate use of feedback, both inadvertent and deliberate. CONCLUSION: The style and content of consultations may be considered as separate dimensions, an approach that may help doctors adapt their communication appropriately to different consultations. Patient feedback focused on communication skills is appropriate, but there are potential risks. PRACTICE IMPLICATIONS: Doctors should consider the transactional or relational preference of a patient in approaching a consultation. Patient feedback can deliver benefits to doctors and patients, but risks must be acknowledged and mitigated against.

User perceptions of multi-source feedback tools for junior doctors.

CONTEXT: The effectiveness of multi-source feedback (MSF) tools, which are increasingly important in medical careers, will be influenced by their users' attitudes. This study compared perceptions of two tools for giving MSF to UK junior doctors, of which one provides mainly textual feedback and one provides mainly numerical feedback. We then compared the perceptions of three groups, including: trainees; raters giving feedback, and supervisors delivering feedback. METHODS: Postal questionnaires about the usability, usefulness and validity of a feedback system were distributed to trainees, raters and supervisors across the north of England. RESULTS: Questionnaire responses were analysed to compare opinions of the two tools and among the different user groups. Overall there were few differences. Attitudes towards MSF in principle were positive and the tools were felt to be usable, but there was little agreement that they could effectively identify doctors in difficulty or provide developmental feedback. The text-oriented tool was rated as more useful for giving feedback on communication and attitude, and as more useful for identifying a doctor in difficulty. Raters were more positive than other users about the usefulness of numerical feedback, but, overall, text was felt to be more useful. Some trainees expressed concern that feedback was based on insufficient knowledge of their work. This was not supported by raters' responses, although many did use indirect information. Trainees selected raters mainly for the perceived value of their feedback, but also based on personal relationships and the simple pragmatics of getting a tool completed. DISCUSSION: Despite positive attitudes to MSF, the perceived effectiveness of the tools was low. There are small but significant preferences for textual feedback, although raters may prefer numerical scales. Concerns about validity imply that greater awareness of contextual and psychological influences on feedback generation is necessary to allow the formative benefits of MSF to be optimised and to negate the risk of misuse in high-stakes contexts.

Asking the right questions and getting meaningful responses: 12 tips on developing and administering a questionnaire survey for healthcare professionals.

Questionnaires provide a useful and versatile tool for new and occasional researchers, and can be applied to a wide range of topics. This paper provides simple guidance on some of the potential pitfalls in developing and running a questionnaire study, and how to avoid them. Each tip is illustrated with a real-life example from the development of a UK-wide questionnaire survey of trainee doctors and their educational supervisors.