Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner--qualitative and summative findings.

OBJECTIVE: To identify collaborative instances and hindrances and to produce a model of collaborative practice. METHODS: A 12-month (2005-2006) mixed methods clinical case study was carried out in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multi-professional emergency care practitioners (ECPs), interviews with 45 ECPs and stakeholders, and an audit of 611 patients RESULTS: Using a generic qualitative approach, observational records and interviews showed that ECPs' numerous links with other professions were influenced by three major themes as follows. (i) The ECP role: for example, "restricted transport codes" of communication, focus on reducing admissions, frustrations about patient tasking and conflicting views about leadership and team work. (ii) Education and training: drivers for multi-professional clinically focussed graduate level education, requirements for skill development in minor injury units (MIUs) and general practice, and the need for clinical supervision/mentorship. (iii) Cultural perspectives: a "crew room" blue collar view of inter-professional working versus emerging professional white collar views, power and communication conflicts, and a lack of understanding of the ECPs' role. The quantitative findings are reported elsewhere. CONCLUSIONS: The final model of collaborative practice suggests that ECPs are having an impact on patient care, but that improvements can be made. We recommend the appointment of ECP clinical leads, degree level clinically focussed multi-professional education, communication skills training, clinical supervision and multi-professional ECP appointments.

Collaborative practices in unscheduled emergency care: role and impact of the emergency care practitioner--quantitative findings.

OBJECTIVE: To identify collaborative instances and hindrances and to produce a model of collaborative practice. METHODS: A 12 month (2005-6) mixed methods clinical case study in a large UK ambulance trust. Collaboration was measured through direct observational ratings of communication skills, teamwork and leadership with 24 multiprofessional emergency care practitioners (ECPs); interviews with 45 ECPs and stakeholders; and an audit of 611 patients. RESULTS: Quantitative observational ratings indicated that the higher the leadership rating the greater the communication ability (p < or = 0.001) and teamwork (p < or = 0.001), and the higher grade ECPs were rated more highly on their leadership performance. From the patient audit, influences and outputs of collaborative practice are revealed: mean time on scene was 47 mins; 62% were not conveyed; 38% were referred, mainly to accident and emergency; ECPs claimed to make the referral decision in 87% of cases with a successful referral in 96% of cases; and in 66% of cases ECPs claimed that their intervention prevented an acute trust admission. The qualitative interview findings, final collaborative model and recommendations are reported in another paper. CONCLUSIONS: The collaborative performance of ECPs varies, but the ECPs' role does appear to have an impact on collaborative practices and patient care. Final recommendations are reported with the qualitative results elsewhere.

The training/service continuum: exploring the training/service balance of senior house officer activities.

BACKGROUND: The continued reduction in junior doctors' hours in the UK has made it necessary to re-examine traditional assumptions about the synonymous natures of training and service. This paper researches senior house officers' (SHOs) perceptions of 'service' and 'training', with reference to where they place activities along the training/service continuum, and the factors that lead them to classify these activities in the way they do. METHODS: Questionnaires were sent to all identified SHOs at Plymouth Hospitals NHS Trust (40% response rate). Three focus groups were held with 5 SHOs, 3 consultants and 2 clinical tutors. Quantitative data derived from the questionnaires were analysed using spss. Qualitative data collected in the focus groups was coded with the aid of n6, which facilitated the thematic analysis of transcripts. RESULTS: Analysis of the quantitative data allowed the construction of the training/service continuum diagram. Identified factors affecting the perceived training/service balance of SHO activities included: frequency, time, type and nature of work, number of patients, supervision, interaction, other commitments, purpose and focus of the activity, the individual trainee and trainer, and experience and competence. DISCUSSION: It is no longer appropriate to assume that all junior doctor activities represent either training or service individually: activities are perceived differently along the training/service continuum depending on their execution and their relation to the SHOs' learning curves. Within the reduced hours framework, it is necessary to match this balance to experience, in order for both training and service requirements to be satisfied.