Pre-prescribing: Creating a zone of proximal development where medical students can safely fail.

PURPOSE: Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners. METHODS: An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory. RESULTS: Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n = 96, 45%; Agree: n = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail. CONCLUSIONS: This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.

Learning beyond a single field of nursing through a virtual case-based approach to pre-registration nurse education.

Ensuring that pre-registration student nurses gain the richness of clinical practice to allow them to feel confident and knowledgeable to care for patients of the 21st century is often a challenge. Clinical practice challenges often mean that students will be strategic learners. This article discusses the development of a virtual case-based learning site to provide a rich experience for students to learn.

The pen is mightier than the sword. Reinstating patient care as the object of prescribing education.

Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on-call simulation.

BACKGROUND: Current research shows that many UK medical graduates continue to feel underprepared to work as a junior doctor. Most research in this field has focused on new graduates and employed the use of retrospective self-rating questionnaires. There remains a lack of detailed understanding of the challenges encountered in preparing for clinical practice, specifically those faced by medical students, where relevant educational interventions could have a significant impact. Through use of a novel on-call simulation, we set out to determine factors affecting perceived preparation for practice in final year medical students and identify ways in which we may better support them throughout their undergraduate training. METHODS: 30 final year medical students from Imperial College London participated in a 90-minute simulation on hospital wards, developed to recreate a realistic on-call experience of a newly qualified doctor. Students partook in pairs, each observed by a qualified doctor taking field notes on their decisions and actions. A 60-minute semi-structured debrief between observer and student pair was audio-recorded for analysis. Field notes and students' clinical documentation were used to explore any challenges encountered. Debrief transcripts were thematically analysed through a general inductive approach. Cognitive Load Theory (CLT) was used as a lens through which to finalise the evolving themes. RESULTS: Six key themes emerged from the on-call simulation debriefs: information overload, the reality gap, making use of existing knowledge, negative feelings and emotions, unfamiliar surroundings, and learning 'on the job'. CONCLUSIONS: The combination of high fidelity on-call simulation, close observation and personalised debrief offers a novel insight into the difficulties faced by undergraduates in their preparation for work as a junior doctor. In using CLT to conceptualise the data, we can begin to understand how cognitive load may be optimised within this context and, in doing so, we highlight ways in which undergraduate curricula may be adapted to better support students in their preparation for clinical practice. Recommendations are centred around enhancing the expertise of the learner through 'whole task' training approaches and integrated learning, as well as navigating negative emotions and supporting lifelong 'learning while working'.

How Does the Proportion of Child-Specific Content of Pre-Registration Nursing Programmes in Higher Education Institutions Impact Upon Newly Qualified Registered Nurses' Perceptions of Preparedness to Care for Children, Young People, and Their Families? A Narrative Review Protocol.

This paper presents a narrative review protocol to explore how the proportion of child-specific content of pre-registration programmes in universities impact upon newly qualified nurses' perceptions of preparedness to care for children, young people (CYP), and their families. The preparation and education to become a nurse who cares for children and young people differs from country to country. Providers of pre-registration nurse education offer routes into nursing from diploma to degree and in some countries post-graduate routes. The United Kingdom offers pre-registration programmes leading to qualifying as a children's nurse whereas programmes in countries such as the USA and Canada lead to a professional registration as a registered nurse with postgraduate study to specialize in areas such as pediatrics. The role of pre-registration nursing programmes is to facilitate preparedness for practice. Preparation for practice can include theoretical teaching and practice learning through simulation and face-to-face experience with countries requiring different numbers of practice hours to be completed. Although practice hours are central to nursing education, there is limited evidence on the impact and portion of child-specific content, including clinical learning in preparation of newly qualified nurses to care for CYP and their families. A preliminary search of Prospero, CINAHL, Medline and Cochrane Database indicates that there are no current or in progress reviews identified. The Population of interest, Exposure of interest, and Outcome framework were used to define the research question and inform the eligibility criteria. The review will consider different research designs if related to the research question. The search strategy will conform to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines for systematic reviews. Two independent reviewers will be involved in the screening progress to determine the final studies for inclusion. Eligible studies will be assessed for methodological quality using the Joanna Briggs Institute critical appraisal tools. Extraction of study characteristics and data related to the research question will be extracted into a predefined table. Data synthesis will be conducted using a descriptive analytical approach to summarize extracted data.

Innovations in nurse education: creating the multisensory learning approach of The WISE Room.

BACKGROUND: Nursing students often face anxiety and cognitive overload, leading to high attrition rates; meanwhile, traditional pastoral interventions have proved insufficient. A novel, digitally enhanced learning environment named The Wellbeing in Student Education (WISE) Room, was introduced as an alternative at a UK university. AIMS: This study investigated the impact of The WISE Room, a 4m × 4m digital platform containing touch-interactive walls, co-created with students and academic staff, designed to promote insight through immersive experiences beyond traditional learning settings. METHODS: A mixed-methods approach was adopted, collecting data from nursing students, healthcare staff and academic faculty. Data were collected at three stages, each corresponding with the iterative development of The WISE Room, including an evaluation of the intervention. RESULTS: Feedback from 240 participants was positive. In Phase 2 of the study, 93% of the 79 students and 21 staff who visited the room and completed a survey were satisfied with the room's suitability in three key areas: emotional wellbeing, academic readiness, and placement preparedness. CONCLUSION: The WISE Room has proved effective in supporting nursing students' wellbeing, and educational and placement preparation requirements. Its multisensory, digital and experiential nature is beneficial for students throughout their learner journey. Additional trials and content development will be required to enhance the learning and teaching experience further.

Exploring clinical facilitation and student learning on undergraduate nursing placements through a community of practice lens: A qualitative study.

Background: High-quality clinical placement experiences are important for preparing undergraduate student nurses for practice. Clinical facilitation and support significantly impact student placement experiences and their development of skills, knowledge, and attitudes in the healthcare setting.Aim: This research aimed to explore university-employed clinical facilitators' perspectives on providing quality clinical facilitation and student learning on placement.Design: An exploratory, descriptive research design was used to examine the perspectives of n = 10 university-employed clinical facilitators working in regional New South Wales, Australia (March 2020-December 2021).Methods: Semi-structured interviews were used to explore the experiences of a purposeful sample of university-employed clinical facilitators. Data was thematically analysed using Miles et al.'s (2014) qualitative data analysis framework.Results: Five key themes were identified 1) relationships at the core of quality, 2) a culture of commitment to student learning, 3) connection to the curriculum, 4) examining the model, and 5) empowering growth and development. Clinical facilitators perceive their role as misunderstood, undervalued, and isolating and that they require further preparation and ongoing professional development to provide quality facilitation. Building rapport and relationships with staff and students was at the core of quality clinical facilitation.Conclusions: The clinical facilitator role has an important function in preparing student nurses for practice and needs further recognition and continued professional development. Education providers and healthcare organisations need to examine strategies to provide inclusive and supportive work environments, building communities of practice for clinical facilitators and stakeholders to share their experiences and knowledge, promoting individual and group learning, thus improving the student placement experience and fostering the professional identity of clinical facilitators.

An exploration of third-year student midwives' experiences of high-risk module assessment in preparation for practice and real-world emergencies.

Five third-year student midwives were interviewed to assess the impact the assessment of obstetric emergencies had on their perceived confidence to manage them correctly in practice. Using purposive sampling and semi-structured interviews, a qualitative descriptive research was conducted. Four themes were identified: OSCE as a form of assessment, Impact of module and assessment, acquisition of knowledge and ways of improving assessment Participants highlighted that assessments act more as an incentive to study and learn and seemed to bear little relevance on their long-term impact on practice confidence. All interviewed students appear to believe that most of their knowledge was acquired through simulation-based learning, lectures, study revision, and clinical encounters of emergencies. Additionally, the assessment undertaken was felt by them not to be comprehensive enough and needed the incorporation of a variety of stations to assess the students' knowledge fully. Recommendations on improvement to assessments to maximise students' confidence and knowledge acquisition have been made.

Final year pre-registration student nurses perceptions of which taught theoretical knowledge is important for practice.

This research illuminates the perceptions of eighteen final year undergraduate pre-registration student nurses, to understand what theoretical knowledge was perceived to be useful during their pre-registration nursing education, and what was not. The research adopted a qualitative phenomenological approach, and utilised a sample size of eighteen final year student nurses as the data source. The data collection method consisted of semi-structured interviews and the study took place at a Higher Education Institution within the North West of England approved to provide pre-registration nurse education. Participants provided their data during their final year of their undergraduate pre-registration nursing programme, via semi-structured, digitally recorded interviews, which were transcribed verbatim. The transcribed interviews were then analysed using Interpretive Phenomenological Analysis. The findings generated three themes, these were; important knowledge to learn for everyday practice, irrelevant for my future role, and, can we have some more? Findings demonstrate what aspects of the taught curriculum student nurses perceive to be of use to their practice, and why they perceive this to be the case. This affects how student nurses approach their learning during their nursing education. In addition it was clear what participants perceived was not useful for their practice and why this was the case. Additionally, participants offered suggestions of what they would also like adding to their curriculum, and provided insights for what they would like adding to the curriculum, which can be used for enhancing this. This is useful when developing future curricula to understand which aspects student nurses learn in a deep and superficial way. This can provide a useful insight for to ensure that patient care is not compromised.

Mindset and its relationship to anxiety in clinical veterinary students.

This study investigated anxiety, one aspect of mental wellbeing, in fourth year veterinary students before the final clinical section of their course (intramural rotations (IMR)). It explored the relationship between reported anxiety and 'mindset': an individual's view on the ability to develop (eg, improve intelligence). Questionnaires were completed by 130 students. Students were mindset typed for ability and personality and rated their anxiety towards IMR. Students with different overall mindsets ('strong growth', 'growth' and 'fixed') were invited to participate in focus groups, to discuss causes of their anxieties. Quantitative results indicated 63.1 per cent of students had strong growth or growth mindsets overall, and that females were more fixed mindset-oriented than males. Females reported significantly greater anxiety than males. A fixed mindset view overall, and of ability, were significantly correlated with increased anxiety, while mindset view of personality was not. Students provided various reasons for their anxieties, which differed with mindset. Fixed mindset students (n=2) focused on concerns about knowledge, whereas growth students (n=6) were also anxious about work-life balance and future work. Growth students saw clinicians as future colleagues, rather than intimidating teachers. Students reported an awareness of being graded, although growth students were aware that IMR are learning opportunities.

A woman's hand and a lion's heart: Skills and attributes for rural midwifery practice in New Zealand and Scotland.

OBJECTIVE: the complex and challenging nature of rural midwifery is a global issue. New Zealand and Scotland both face similar ongoing challenges in sustaining a rural midwifery workforce, and understanding the best preparation for rural midwifery practice. This study aimed to explore the range of skills, qualities and professional expertise needed for remote and rural midwifery practice. DESIGN: online mixed methods: An initial questionnaire via a confidential SurveyMonkey® was circulated to all midwives working with rural women and families in New Zealand and Scotland. A follow-up online discussion forum offered midwives a secure environment to share their views about the specific skills, qualities and challenges and how rural midwifery can be sustained. Data presented were analysed using qualitative descriptive thematic analysis. SETTING AND PARTICIPANTS: 222 midwives participated in this online study with 145 from New Zealand and 77 from Scotland. FINDINGS: underpinning rural midwifery practice is the essence of 'fortitude' which includes having the determination, resilience, and resourcefulness to deal with the many challenges faced in everyday practice and to safeguard midwifery care for women within their rural communities. KEY CONCLUSIONS: rural midwives in New Zealand and Scotland who work in rural practice specifically enhance skills such as preparedness, resourcefulness and developing meaningful relationships with women and other colleagues which enables them to safeguard rural birth. IMPLICATIONS FOR PRACTICE: findings will inform the preparation of midwives for rural midwifery practice.

Preparing medical students for clinical practice: easing the transition.

The transition from medical student to junior doctor is a challenge; the UK General Medical Council has issued guidance emphasizing the importance of adequate preparation of medical students for clinical practice. This study aimed to determine whether a junior doctor-led simulation-based course is an effective way of preparing final year medical students for practice as a junior doctor.We piloted a new 'preparation for practice' course for final year medical students prior to beginning as Foundation Year 1 (first year of practice) doctors. The course ran over three days and consisted of four simulated stations: ward round, prescribing, handover, and lessons learnt. Quantitative and qualitative feedback was obtained.A total of 120 students attended (40 on each day) and feedback was collected from 95 of them. Using a scale of 1 (lowest) to 5 (highest), feedback was positive, with 99% and 96% rating 4 or 5 for the overall quality of the program and the relevance of the program content, respectively. A score of 5 was awarded by 67% of students for the ward round station; 58% for the handover station; 71% for the prescribing station, and 35% for the lessons learnt station. Following the prescribing station, students reported increased confidence in their prescribing.Preparation for practice courses and simulation are an effective and enjoyable way of easing the transition from medical student to junior doctor. Together with 'on-the-job' shadowing time, such programs can be used to improve students' confidence, competence, and ultimately patient safety and quality of care.

Using an Objective Structured Clinical Examination for Bachelor of Midwifery students' preparation for practice.

BACKGROUND: Contemporary midwifery practice needs a rigorous and standardised assessment of practical skills, and knowledge to ensure that safety is maintained for both women and neonates before, during and after childbirth. AIM: To evaluate the use of Best Practice Guidelines (BPG) for Objective Structured Clinical Examinations (OSCE) as a standardised tool to develop clinical competence of Bachelor of Midwifery students. METHOD: A pragmatic mixed method approach with surveys, focus groups and interviews was used to evaluate the OSCEs for first year students. Quantitative and qualitative data were combined to understand student and academic perceptions of students' confidence for clinical practice following the OSCE. FINDINGS: Thirty-four students responded to surveys (response rate 94%); and 13 participated in focus groups. Two academic lecturers participated in an interview (100%). Two main themes emerged (1) the OSCEs improved student confidence (2) the OSCEs were relevant and prepared students for practice. Most students indicated that they practised for the OSCE using an integrated approach (70%), and that this assisted them in their approach to the assessment of the neonate or post-partum mother. CONCLUSION: The use of BPGs to ensure that OSCEs focus on important aspects of knowledge and practice helped students to learn and to perform well. Students' confidence in their ability for the imminent professional experience placement was high. OSCEs designed with the BPGs should be implemented broadly across midwifery education to enhance students' competence and provide rigorous meaningful assessment.