Investigating physiotherapy stakeholders' preferences for the development of performance-based assessment in practice education.

OBJECTIVES: Discrete choice experiments (DCEs) are used in healthcare to measure the relative importance that stakeholders give to different features (or attributes) of medical treatments or services. They may also help to address research questions in health professional education. Several challenges exist regarding the performance-based assessment process (PBA) employed in physiotherapy practice-based education, a process which determines students' readiness for independent practice. Evidence highlights many commonalities among these challenges, but it is unknown which factors are the most important to stakeholders. The use of DCE methodology may provide answers and help to prioritise areas for development. Thus, this study employed DCE to identify clinical educators', practice tutors and physiotherapy students' preferences for developing the PBA process in physiotherapy. DESIGN: Attributes (aspects of the PBA process known to be important to stakeholders) were derived from focus group interviews conducted with three groups; physiotherapy students, clinical educators (practising clinicians) and practice tutors (dedicated educational roles in the workplace). These attributes included the PBA tool, grading mechanisms, assessors involved, and, feedback mechanisms. Preferences for each group were calculated using a logistic regression model. RESULTS: Seventy-two students, 124 clinical educators and 49 practice tutors (n=245) participated. Priorities identified centred primarily on the mandatory inclusion of two assessors in the PBA process and on refinement of the PBA tool. CONCLUSION: Employment of DCE enabled the prioritisation of stakeholder-informed challenges related to PBA in physiotherapy practice-based education. This corroborates findings from previous qualitative work and facilitates a prioritised pathway for development of this process.

Juggling roles and generating solutions; practice-based educators' perceptions of performance-based assessment of physiotherapy students.

OBJECTIVES: Physiotherapy lacks the significant body of evidence that underpins performance-based assessments in disciplines such as medicine and nursing. In particular, very few studies have examined stakeholder perspectives of the process. This study set out to explore the perceptions of clinicians who undertake student assessment in the workplace in order to inform further development of performance-based assessment in physiotherapy. DESIGN: A qualitative, descriptive design was employed where focus group interviews were utilised for data collection. Inductive thematic analysis was used to analyse the data. PARTICIPANTS: Clinical educator and practice tutor volunteers affiliated with three Irish universities participated in one of seven focus groups (n=46). RESULTS: Two themes were identified; 1) Tensions in the clinical learning environment, 2) An optimal PBA process. The first theme describes clinical educators' struggle with juggling multiple roles and highlights the challenges of sustaining a balance between student mentoring and patient care. The second theme outlines factors perceived to contribute to an optimal performance-based assessment process; these include maintaining aspects of the current process and expanding the employment of dedicated educational roles in the workplace. CONCLUSION: Our findings illustrate a complex working environment for clinicians involved in student supervision and assessment. A dedicated educational role was perceived to provide a more standardised and rigorous approach to performance-based assessment. These findings provide critical stakeholder-centred insights, which may inform development of this process by addressing critical aspects deemed to facilitate and challenge clinical educator's roles as assessors.

Clinical performance assessment tools in physiotherapy practice education: a systematic review.

BACKGROUND: Clinical performance assessment tools (CPATs) used in physiotherapy practice education need to be psychometrically sound and appropriate for use in all clinical settings in order to provide an accurate reflection of a student's readiness for clinical practice. Current evidence to support the use of existing assessment tools is inconsistent. OBJECTIVES: To conduct a systematic review synthesising evidence relating to the psychometric and edumetric properties of CPATS used in physiotherapy practice education. DATA SOURCES: An electronic search of Web of Science, SCOPUS, Academic Search Complete, AMED, Biomedical Reference Collection, British Education Index, CINAHL plus, Education Full Text, ERIC, General Science Full Text, Google Scholar, MEDLINE, UK and Ireland Reference Centre databases was conducted identifying English language papers published in this subject area from 1985 to 2015. STUDY SELECTION: 20 papers were identified representing 14 assessment tools. DATA EXTRACTION AND SYNTHESIS: Two reviewers evaluated selected papers using a validated framework (Swing et al., 2009). RESULTS: Evidence of psychometric testing was inconsistent and varied in quality. Reporting of edumetric properties was unpredictable in spite of its importance in busy clinical environments. No Class 1 recommendation was made for any of the CPATs, and no CPAT scored higher than Level C evidence. CONCLUSIONS: Findings demonstrate poor reporting of psychometric and edumetric properties of CPATs reviewed. A more robust approach is required when designing CPATs. Collaborative endeavour within the physiotherapy profession and interprofessionally may be key to further developments in this area and may help strengthen the rigour of such assessment processes.

Desires versus reality of medical and health science summer student research opportunities.

BACKGROUND: Medical and health science students are increasingly becoming involved in research throughout their undergraduate education. However, the quality of student research outcomes has recently come into question. METHODS: A cross-sectional online survey of Irish medical and health science student who received a summer student research grant in 2014 and 2015. RESULTS: Of 56 respondents (40.6% response rate), increasing competitiveness for future career opportunities was the highest rated motivational factor for pursuing research. Respondents were most often involved in analysing data (n = 51; 91.1%) and collecting data (n = 46; 82.1%). Respondents most often identified that they would have liked to be involved in coming up with research question (n = 34; 60.7%), while in reality, they were least commonly involved in that aspect (n = 14; 25.0%). CONCLUSION: Despite the desire by summer research students to be involved in early components of research project design, this only occasionally occurs. Summer student research programs should explore the possibility of early involvement of students in the research design phase.

How do clinicians become teachers? A communities of practice perspective.

There is widespread acceptance that clinical educators should be trained to teach, but faculty development for clinicians is undermined by poor attendance and inadequate learning transfer. As a result there has been growing interest in situating teacher development initiatives in clinical workplaces. The relationship between becoming a teacher and clinical workplace contexts is under theorised. In response, this qualitative research set out to explore how clinicians become teachers in relation to clinical communities and institutions. Using communities of practice (CoP) as a conceptual framework this research employed the sensitising concepts of regimes of competence and vertical (managerial) and horizontal (professional) planes of accountability to elucidate structural influences on teacher development. Fourteen hospital physicians completed developmental timelines and underwent semi-structured interviews, exploring their development as teachers. Despite having very different developmental pathways, participants' descriptions of their teacher identities and practice that were remarkably congruent. Two types of CoP occupied the horizontal plane of accountability i.e. clinical teams (Firms) and communities of junior doctors (Fraternities). Participants reproduced teacher identities and practice that were congruent with CoPs' regimes of competence in order to gain recognition and legitimacy. Participants also constructed their teacher identities in relation to institutions in the vertical plane of accountability (i.e. hospitals and medical schools). Institutions that valued teaching supported the development of teacher identities along institutionally defined lines. Where teaching was less valued, clinicians adapted their teacher identities and practices to suit institutional norms. Becoming a clinical educator entails continually negotiating one's identity and practice between two potentially conflicting planes of accountability. Clinical CoPs are largely conservative and reproductive of teaching practice whereas accountability to institutions is potentially disruptive of teacher identity and practice.

A survey of asylum seekers' general practice service utilisation and morbidity patterns.

To compare Irish asylum seekers to other General Medical Scheme (GMS) patients possessing Irish citizenship in terms of their utilisation of GP services, morbidity patterns and consultation outcomes. A retrospective 1 year study on patient records in two Galway City practices was performed. All asylum seekers who were patients of the two practices were compared with two controls each from a population of GMS patients with Irish citizenship matched for age, sex, and GMS status. Demographic information was recorded. For each consultation over the 12 months the diagnosis using the ICPC coding system' and consultation outcomes were recorded. Data was collected on 171 asylum seekers and 342 Irish citizens. The majority of asylum seekers registered in the two practices were from Nigeria (43.9%). The age of cases ranged from 1 month to 60 years of age with a median of 26. 45.8% were female and 54% male. The mean number of visits per asylum seeker per year was 5.16 (SD 3.12) whereas the mean for Irish Citizens was 2.31 (SD 2.33) (p = 0.0001). Asylum seekers had a significantly higher likelihood of being assigned diagnoses in the disease systems of psychiatry, dermatology, neurology, muscuioskeletal disease, urology, respiratory, ENT, Obstetrics and Gynaecology and gastroenterology. Asylum seekers were five times more likely to be diagnosed with psychiatric illness than Irish citizens. Specifically they had a significantly higher chance of being diagnosed with anxiety (odds ratio = 3.17 [95% CI 1.1,8.68]). Overall, the frequency of prescription as a consultation outcome was higher for asylum seekers. Asylum seekers were prescribed more antibiotics and psychiatric medications but Irish GMS had higher prescription rates for drugs outside of these categories. Referral rates were higher in the asylum seeker group. Asylum seekers attended the GP more frequently than their Irish counterparts. They were more likely to be diagnosed with psychological problems than the Irish. Studies have shown a strong link between psychological illness and being a "frequent attender" in general practice. This could explain the higher than average frequency of attendance in this group. They were more likely to be prescribed antibiotics and psychiatric medications. This study provides the first quantitative data to inform debate regarding the appropriate supply of resources to Irish practices with significant numbers of asylum seekers.

Pre-registration house officers in general practice: the views of GP trainers.

BACKGROUND: Recent changes have led to an upsurge of interest in pre-registration rotations in general practice. In 1998, a national pilot programme of >40 new rotations incorporating general practice was implemented. OBJECTIVE: The aim of this study was to explore the experiences of GPs involved in the four pilot rotations established in South Thames region. METHODS: Semi-structured interviews were conducted with trainers and partners. RESULTS: The supervisory workload for pre-registration house officers (PRHOs) was much greater than that required by registrars. All GPs felt that increased remuneration was important for the future viability of the scheme. The majority of GPs remained supportive of the scheme, although a minority were concerned about the value of the experience gained by PRHOs. There were a few instances in which inadequacies in patient management had to be dealt with subsequently by trainers. The supervisory implications of such events will need to be addressed. CONCLUSION: This significant development in medical education has important implications for GPs and their patients which need further exploration through long-term evaluations.

The doctor-patient relationship: from undergraduate assumptions to pre-registration reality.

OBJECTIVES: To describe the ways in which the doctor-patient relationship experienced by newly qualified pre-registration house officers (PRHOs) differed from their undergraduate expectations. DESIGN: Qualitative study in which in-depth semistructured interviews were carried out with each PRHO within 4-6 weeks of the start of their first job. SETTING: Three teaching hospitals, three district general hospitals and four general practices in south-east England. PARTICIPANTS: 24 newly qualified PRHOs. RESULTS: A number of differences were identified by PRHOs. These were caused in part by the impact of factors such as the shortage of time, which could lead to emotional 'blunting'. Some PRHOs were changing their ideas about what constitutes a 'good' doctor, and were redefining the meaning of a 'professional' relationship. The relationships of PRHOs with patients were also affected by the attitudes of their senior colleagues. For example, where PRHOs tried to maintain a patient-centred relationship, they could be identified by colleagues as working too slowly. PRHOs working in general practice were able to utilize and improve their communication skills with patients, but found it difficult to transfer these skills back into the hospital setting. CONCLUSIONS: Despite receiving substantial undergraduate education on how best to communicate with patients, a variety of factors conspired to prevent hospital-based PRHOs from utilizing this information. Building on these findings, a number of recommendations are made to help improve practice.

The clinical and educational experiences of pre-registration house officers in general practice.

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.

Pre-registration house officer rotations incorporating general practice: does the order of rotation matter?

CONTEXT: In relation to pre-registration house officer (PRHO) rotations incorporating general practice, previous research has recommended that where possible, no PRHO should undertake general practice as the first placement, because of the difficulties encountered. It was recognized that logistically, this could make such schemes almost unworkable. Within the context of a larger qualitative evaluation comparing how 24 PRHOs learned in hospital and general practice settings, the issue of rotation order was explored. METHODS: In-depth semistructured interviews were conducted with the 12 PRHOs who were involved in general practice rotations. They were interviewed at the beginning and end of the PRHO year, and following their return to hospital work after the general practice placement. RESULTS: Each rotation order had both advantages and disadvantages, with no particular rotation order being obviously better or worse for the PRHOs involved. CONCLUSIONS: This small qualitative evaluation has highlighted a number of advantages and disadvantages specific to each rotation order, and makes some practical recommendations to help alleviate the problems encountered. It is important that future evaluations of similar schemes consider this issue, as there are conflicting reports about the significance of the rotation order.

PRHOs in primary care: what is happening out there?

Preregistration house officer (PRHO) placements in general practice were introduced throughout Britain in August 1998. This paper describes an evaluation of PRHOs in primary care rotations in South Thames during 1998-99. There are important messages for both educational supervisors and undergraduates considering a PRHO in primary care rotation.

Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants.

AIMS: To explore the concerns of pre-registration house officers (PRHOs) and the views of hospital consultants in relation to pre-registration rotations with a general practice component. METHOD: As part of a larger qualitative study evaluating how a group of 24 PRHOs learn in hospital and primary care settings, face-to-face semistructured interviews were conducted with the PRHOs, and semistructured telephone interviews with the PRHOs' educational supervisors were carried out. RESULTS: The interviews with the PRHOs highlighted their concerns about how consultants might view PRHO rotations into general practice. However, the majority of consultants interviewed recognized and valued specific aspects of the experience to be gained by PRHOs in general practice, including the relationship between primary and secondary care; communications skills; specific clinical skills, and an understanding of the natural course of illnesses. The experience was seen as valuable for PRHOs considering either a general practice or a hospital career. Of the 17 consultants, 10 were also confident that 4-month placements in surgery and medicine would give PRHOs adequate experience in either specialty, providing the placements were sufficiently busy. CONCLUSIONS: Medical school deans and medical students considering PRHO rotations with a general practice component can be encouraged by the fact that, in this small study, the majority of hospital consultants interviewed valued the specific experience offered by these rotations, and felt that adequate medical and surgical experience could be gained in busy 4-month hospital placements.

A surgical career? The views of junior women doctors.

OBJECTIVE: To explore female pre-registration house officers (PRHOs) views of surgery as a possible career choice. DESIGN AND PARTICIPANTS: In this qualitative study in-depth semistructured interviews were carried out with 15 female PRHOs. They were part of a larger sample of 24 PRHOs (15 women and nine men) who were being interviewed primarily to explore their ways of learning in both hospital and general practice settings. This paper focuses on the responses of the 15 women in relation to surgery as a possible career choice. METHODS: Interviews incorporated a checklist of topics to encourage participants to discuss their experiences of learning and working as PRHOs, including factors which had impacted on future career choices. Common themes were identified by comparing narratives. RESULTS: Only three of the 15 women PRHOs were considering a career in surgery. The importance of positive surgical placements and contact with female surgical registrars and consultants during undergraduate training was highlighted. The changing nature of the surgical PRHO job with its lack of surgical exposure was unlikely to change the future career plans of female PRHOs. Factors such as the perceived difficulties of combining a family with a surgical career and the lack of women in particular surgical specialties were of considerable concern. CONCLUSIONS: Strategies for ensuring that female medical students receive a more positive view of surgery need to be implemented. Surgical PRHO jobs should be re-evaluated to assess the surgical experience being gained by doctors, particularly in light of the reduction in junior doctors' hours. Despite policy initiatives, many newly qualified women doctors have already decided against a surgical career.

Patients' perceptions of changes in their blood pressure.

OBJECTIVES: (1) To investigate patients' experience of changes in their blood pressure (BP) in an every day setting and the accuracy of patients' predictions; and (2) to examine what influences patients' belief that they can tell when their BP is up. SUBJECTS: A total of 102 hypertensive patients were recruited sequentially as they presented for routine BP checks. The setting was an inner city general practice. DESIGN: Patients attended for BP checks on a weekly basis. Before each check they were asked whether they thought their BP was higher, lower or the same as usual. Subjects were classified as predictors if they thought they could tell when their BP was up. On completing their series of BP checks each subject completed symptom and Hospital Anxiety and Depression questionnaires. MAIN OUTCOME MEASURES: Accuracy of BP predictions, BP levels and variability, number of symptoms reported and anxiety level. RESULTS: One hundred and two hypertensive patients entered the study of whom 51 patients were predictors. The majority (86%) of predictors could not accurately predict their BP. There were no significant differences in either BP or variability between predictors and non-predictors. Predictors were significantly more anxious and reported more symptoms than non-predictors. CONCLUSIONS: For the majority of predictors there is no significant relationship between predictions of BP and clinical measurements. Predictor status is associated with the reporting of more symptoms and higher levels of anxiety. Doctors should counsel patients against using subjective BP assessments to guide their use of antihypertensive medication.