Leadership and followership in the healthcare workplace: exploring medical trainees' experiences through narrative inquiry.

OBJECTIVES: To explore medical trainees' experiences of leadership and followership in the interprofessional healthcare workplace. DESIGN: A qualitative approach using narrative interviewing techniques in 11 group and 19 individual interviews with UK medical trainees. SETTING: Multisite study across four UK health boards. PARTICIPANTS: Through maximum variation sampling, 65 medical trainees were recruited from a range of specialties and at various stages of training. Participants shared stories about their experiences of leadership and followership in the healthcare workplace. METHODS: Data were analysed using thematic and narrative analysis. RESULTS: We identified 171 personal incident narratives about leadership and followership. Participants most often narrated experiences from the position of follower. Their narratives illustrated many factors that facilitate or inhibit developing leadership identities; that traditional medical and interprofessional hierarchies persist within the healthcare workplace; and that wider healthcare systems can act as barriers to distributed leadership practices. CONCLUSIONS: This paper provides new understandings of the multiple ways in which leadership and followership is experienced in the healthcare workplace and sets out recommendations for future leadership educational practices and research.

Dimensions, discourses and differences: trainees conceptualising health care leadership and followership.

CONTEXT: As doctors in all specialties are expected to undertake leadership within health care organisations, leadership development has become an inherent part of medical education. Whereas the leadership literature within medical education remains mostly focused on individual, hierarchical leadership, contemporary theory posits leadership as a group process, which should be distributed across all levels of health care organisation. This gap between theory and practice indicates that there is a need to understand what leadership and followership mean to medical trainees working in today's interprofessional health care workplace. METHODS: Epistemologically grounded in social constructionism, this research involved 19 individual and 11 group interviews with 65 UK medical trainees across all stages of training and a range of specialties. Semi-structured interviewing techniques were employed to capture medical trainees' conceptualisations of leadership and followership. Interviews were audiotaped, transcribed verbatim and analysed using thematic framework analysis to identify leadership and followership dimensions which were subsequently mapped onto leadership discourses found in the literature. RESULTS: Although diversity existed in terms of medical trainees' understandings of leadership and followership, unsophisticated conceptualisations focusing on individual behaviours, hierarchy and personality were commonplace in trainees' understandings. This indicated the dominance of an individualist discourse. Patterns in understandings across all stages of training and specialties, and whether definitions were solicited or unsolicited, illustrated that context heavily influenced trainees' conceptualisations of leadership and followership. CONCLUSIONS: Our findings suggest that UK trainees typically hold traditional understandings of leadership and followership, which are clearly influenced by the organisational structures in which they work. Although education may change these understandings to some extent, changes in leadership practices to reflect contemporary theory are unlikely to be sustained if leadership experiences in the workplace continue to be based on individualist models.

Exploring stakeholders' views of medical education research priorities: a national survey.

CONTEXT: Setting research priorities is important when exploring complex issues with limited resources. Only two countries (Canada and New Zealand) have previously conducted priority-setting exercises for medical education research (MER). This study aimed to identify the views of multiple stakeholders on MER priorities in Scotland. METHODS: This study utilised a two-stage design to explore the views of stakeholders across the medical education continuum using online questionnaires. In Stage 1, key informants outlined their top three MER priorities and justified their choices. In Stage 2, participants rated 21 topics generated in Stage 1 according to importance and identified or justified their top priorities. A combination of qualitative (i.e. framework analysis) and quantitative (e.g. exploratory factor analysis) data analyses were employed. RESULTS: Views were gathered from over 1300 stakeholders. A total of 21 subthemes (or priority areas) identified in Stage 1 were explored further in Stage 2. The 21 items loaded onto five factors: the culture of learning together in the workplace; enhancing and valuing the role of educators; curriculum integration and innovation; bridging the gap between assessment and feedback, and building a resilient workforce. Within Stage 2, the top priority subthemes were: balancing conflicts between service and training; providing useful feedback; promoting resiliency and well-being; creating an effective workplace learning culture; selecting and recruiting doctors to reflect need, and ensuring that curricula prepare trainees for practice. Participant characteristics were related to the perceived importance of the factors. Finally, five themes explaining why participants prioritised items were identified: patient safety; quality of care; investing for the future; policy and political agendas, and evidence-based education. CONCLUSIONS: This study indicates that, across the spectrum of stakeholders and geography, certain MER priorities are consistently identified. These priority areas are in harmony with a range of current drivers in UK medical education. They provide a platform of evidence on which to base decisions about MER programmes in Scotland and beyond.

Patient safety and communication: a new assessment for doctors trained in countries where language differs from that of the host country: results of a pilot using a domain-based assessment.

OBJECTIVE: Global migration of healthcare workers places responsibility on employers to comply with legal employment rights whilst ensuring patient safety remains the central goal. We describe the pilot of a communication assessment designed for doctors who trained and communicated with patients and colleagues in a different language from that of the host country. It is unique in assessing clinical communication without assessing knowledge. METHODS: A 14-station OSCE was developed using a domain-based marking scheme, covering professional communication and English language skills (speaking, listening, reading and writing) in routine, acute and emotionally challenging contexts, with patients, carers and healthcare teams. Candidates (n=43), non-UK trained volunteers applying to the UK Foundation Programme, were provided with relevant station information prior to the exam. RESULTS: The criteria for passing the test included achieving the pass score and passing 10 or more of the 14 stations. Of the 43 candidates, nine failed on the station criteria. Two failed the pass score and also the station criteria. The Cronbach's alpha coefficient was 0.866. CONCLUSION: This pilot tested 'proof of concept' of a new domain-based communication assessment for non-UK trained doctors. PRACTICE IMPLICATIONS: The test would enable employers and regulators to verify communication competence and safety in clinical contexts, independent of clinical knowledge, for doctors who trained in a language different from that of the host country.

Making sense of feedback experiences: a multi-school study of medical students' narratives.

CONTEXT: Until recently, the perspective of students in the feedback process has been ignored, with strategies for improvement focusing on the tutor and feedback delivery. We employed an original narrative interviewing approach to explore how medical students make sense of their experiences of feedback. METHODS: A qualitative design was adopted employing three individual and 10 group interviews to elicit narratives of feedback experiences from 53 medical students at three 5-year undergraduate programmes in the UK during 2011. Thematic analysis was undertaken of students' understandings of feedback and of their narratives of positive and negative experiences of feedback at medical school. In addition, thematic and discourse analysis of the linguistic and paralinguistic features of talk within the narratives was conducted. RESULTS: Students typically constructed feedback as a monologic process that happened 'to' them rather than 'with' them. They shared 352 distinct narratives of feedback experiences, which were rich in linguistic and paralinguistic features of talk. Through the analysis of the interplay between the 'whats' and 'hows' of student talk, i.e. emotion, pronominal and metaphoric talk and laughter, we were able to understand how students find meaning in their experiences. Students used laughter as a coping strategy, emotion talk as a means to convince the audience of the impact of feedback, pronominal and metaphoric talk to describe their relationship (often adversarial) with their feedback providers and to communicate feelings that they might otherwise struggle to articulate. CONCLUSIONS: This research extends current feedback literature by focusing on medical students' lived experiences of feedback and their emotional impact through narrative. We go on to discuss the educational implications of our findings and to make recommendations for improvement of the feedback process for students, tutors and for institutions.

Levels of reflective thinking and patient safety: an investigation of the mechanisms that impact on student learning in a single cohort over a 5 year curriculum.

Existing research into learning about patient safety focuses on identifying how educational interventions improve educational outcomes but few studies offer evidence that inform educators about the mechanisms involved in learning about patient safety. The current evidence based in undergraduates is also limited to outcomes that relate to knowledge and skills. A realist approach involving three cycles of data collection in a single cohort of students over 5 years used different outcomes in Kirkpatrick's framework to identify the mechanisms that influence students learning about patient safety. Data source 1. Focus groups identified an overarching theoretical model of the mechanisms that influence patient safety learning for medical students. Data source 2 Identified if the mechanisms from data source 1 could be demonstrated at the outcome level of knowledge and attitudes. Data source 3 Established associations between mechanisms and outcomes at skills and behavioural level, in a standardised simulated ward setting. Data source 1: The interpretation of data from seven focus groups involving sixty students identified reflection at two levels of Mezirow's descriptions; reflection and critical reflection as mechanisms that influence learning about error. Data source 2: Sixty-one students participated. The associations found, reflection and knowledge of actions to take for patient safety, r = 0.44 (P = 0.00) and critical reflection and intentions regarding patient safety, r = 0.40 (P = 0.00) Data source 3: Forty-eight students participated. The correlation identified associations between critical reflection and planned changes following feedback was, r = 0.48 (P = 0.00) and reflection and knowledge based errors r = -0.30 (P = 0.03). A realist approach identified two different levels of reflection were associated with different patient safety outcomes for this cohort of students. Critical reflection was associated with attitudes and reflection was associated with knowledge of actions and error behaviours. These findings give educators greater depth of information about the role of reflection in patient safety.

Perceived causes of prescribing errors by junior doctors in hospital inpatients: a study from the PROTECT programme.

INTRODUCTION: Prescribing errors are a major cause of patient safety incidents. Understanding the underlying factors is essential in developing interventions to address this problem. This study aimed to investigate the perceived causes of prescribing errors among foundation (junior) doctors in Scotland. METHODS: In eight Scottish hospitals, data on prescribing errors were collected by ward pharmacists over a 14-month period. Foundation doctors responsible for making a prescribing error were interviewed about the perceived causes. Interview transcripts were analysed using content analysis and categorised into themes previously identified under Reason's Model of Accident Causation and Human Error. RESULTS: 40 prescribers were interviewed about 100 specific errors. Multiple perceived causes for all types of error were identified and were categorised into five categories of error-producing conditions, (environment, team, individual, task and patient factors). Work environment was identified as an important aspect by all doctors, especially workload and time pressures. Team factors included multiple individuals and teams involved with a patient, poor communication, poor medicines reconciliation and documentation and following incorrect instructions from other members of the team. A further team factor was the assumption that another member of the team would identify any errors made. The most frequently noted individual factors were lack of personal knowledge and experience. The main task factor identified was poor availability of drug information at admission and the most frequently stated patient factor was complexity. CONCLUSIONS: This study has emphasised the complex nature of prescribing errors, and the wide range of error-producing conditions within hospitals including the work environment, team, task, individual and patient. Further work is now needed to develop and assess interventions that address these possible causes in order to reduce prescribing error rates.

Student perceptions of a portfolio assessment process.

OBJECTIVES: The objectives of this study were to identify and analyse students' attitudes to the portfolio assessment process over time. METHODS: A questionnaire containing statements and open questions was used to obtain feedback from students at the University of Dundee Medical School, Scotland. The responses to each statement were compared over 4 years (1999, 2000, 2002 and 2003). RESULTS: Response rates were 83% in 1999, 70% in 2000, 89% in 2002 and 88% in 2003. A major finding is that students perceived that portfolio building heightened their understanding of the exit learning outcomes and enabled reflection on their work. Student reactions to the portfolio process were initially negative, although they appreciated that senior staff took time to become familiar with their work through reviewing their portfolios. Student attitudes became more positive over the 4 years as the process evolved. Although portfolio assessment was recognised as supporting student learning, portfolio building was perceived to interfere with clinical learning as a result of the excessive amounts of paper evidence required. CONCLUSIONS: Paperwork should be kept within manageable limits. A student induction process that highlights the importance of providing evidence for achieving all learning outcomes, not just theoretical knowledge and skills, may be helpful in allaying student concern over portfolio building and assessment and support preparation for lifelong learning and reflective clinical practice.

A learning package for medical students in a busy urology department: design, implementation, and evaluation.

OBJECTIVES: The need for innovation in the delivery of quality teaching and learning for undergraduates in urology is driven by a number of factors. An increasing proportion of care is delivered in ambulatory settings, hospital inpatients are increasingly unwell, and the National Health Service staff must find a balance in their dual roles as healthcare providers and clinical teachers. We describe the design, implementation, and evaluation of an innovative learning package for undergraduate medical students in urology. This consisted of a simulated urology outpatient clinic to prepare students for learning in the outpatient environment and an on-line self- and peer-assessed learning exercise to provide students with the necessary clinical knowledge of the core problems in urology and to encourage reflection. METHODS: Action research principles were used to design, deliver, and evaluate a model for teaching and learning in the outpatient setting. Fourth-year medical students at the start of a 1-week clinical teaching block were given the opportunity to participate in a simulated urology outpatient clinic. On-line support material was designed around 2 core clinical problems in urology. The evaluations were gathered using an anonymous on-line questionnaire and a pre- and postcourse test of knowledge for a sample group. RESULTS: Of the students who responded, 100% found the on-line material helpful for learning about the core clinical problems. The results demonstrated a 12% improvement in scores in a knowledge test at 1 week and 18% at 1 month after the teaching block compared with the control group from the previous academic year for which the mean improvement was 7% at 1 week and 8% at 1 month after the teaching program. CONCLUSIONS: The evaluation results demonstrated a positive effect on learning without compromise to the service provided to patients. This could be developed as a model for teaching and learning urology or other specialties.

Can a ward simulation exercise achieve the realism that reflects the complexity of everyday practice junior doctors encounter?

Recent changes in medical education have resulted in an increased focus on patient safety. It is vital that new doctors can recognize and manage acutely-ill patients, as well as work safely and effectively as a member of a multi-professional team. A ward simulation exercise has been developed to provide a safe, but authentic setting to support junior doctors with further practice and feedback. In developing such an exercise realism is important in recreating the complex climate in which the junior doctor has to function as part of the healthcare team in the hospital ward. This paper shares the design methodology of a ward simulation exercise and the views on its authenticity from both the junior doctors and the observers.

Twelve tips for developing and maintaining a simulated patient bank.

Simulated patients have become almost indispensable in the education and training of health care professionals. Their contribution to the creation of a safe, yet realistic, learner centred environment is invaluable. Their support in enabling learners at all stages of their professional careers to develop both competence and confidence through repeated practice helps to ensure that learning from real patients can be maximized. A simulated patient bank can enable tracking and training of simulated patients to be coordinated in an effective and efficient way both for patients and learners. This paper shares experiences of developing a simulated patient bank against the background of changes in health care delivery and education and training. Twelve tips to developing and maintaining a simulated patient bank have been identified. The tips focus on the needs of the simulated patient bank and ensure that training is at an appropriate level for the learners, patient care is not compromised and simulated patients feel they are valued members of the educational team.

An outcome-based approach for teaching prudent antimicrobial prescribing to undergraduate medical students: report of a Working Party of the British Society for Antimicrobial Chemotherapy.

Antibiotic resistance is on the increase. This is evidenced by the almost daily publication of related articles in both professional journals and the media. The Department of Health and the Scottish Executive have published strategies and action plans that highlight the need for prudent use of antimicrobials. A key strategy in facilitating prudent prescribing is the early introduction of the relevant knowledge concepts and skills into the undergraduate medical curriculum. This reflects the need to ensure graduating doctors are fit for practice (General Medical Council) in accordance with evidence-based antibiotic policies. Outcome-based education has gained increasing credibility as an explicit and systematic approach to developing standards for undergraduate prescribing education. This approach enables performance to be measured accurately. This paper provides an introduction to understanding outcome-based education and how it has been applied in the context of prudent antimicrobial prescribing for undergraduate medical education as defined by an expert working party. In addition, the paper shares how this has then been implemented through the development of a new teaching resource custom designed to assist with teaching the skills of antimicrobial prescribing using an outcome framework. To avoid the increase of antibiotic resistance we advocate that the educational approach to prescribing should be one of achieving shared predetermined outcomes, and that the purpose-designed Appropriate Antimicrobial Prescribing for Tomorrow's Doctors (APT) teaching resource should be referred to and used by students, teachers, assessors, curriculum planners and anyone involved in antimicrobial prescribing.

Information-sharing strategies to support practising clinicians in their clinical teaching roles.

If the involvement of practising clinicians in undergraduate clinical teaching is to be retained, strategies that inform them of student expectations and show how their contribution can be integrated to the wider clinical teaching programme must be identified. A variety of information-sharing strategies has been designed and used to communicate with clinicians teaching in Phase 2 of the undergraduate medical curriculum in Dundee. Evaluation of these by the clinical teaching staff has indicated that briefing by students, posters and tutor manuals are more successful information-sharing strategies than formal staff-development sessions.

Using the Ambulatory Care Teaching Centre to develop opportunities for integrated learning.

An Ambulatory Care Teaching Centre (ACTC) has provided an opportunity to develop an integrated teaching programme in a supervised environment which links students' initial clinical experiences in the skills centre with patient-contact in other teaching settings. Second-year students attended 2-h sessions in the ACTC during each block of a systems-based course. Two 'system-sensitive' patients invited from a patient bank enabled students to develop clinical skills previously practised on mannequins and simulated patients and to integrate theoretical material with clinical practice. A programme co-ordinator timetabled student, patient and tutor attendances. Students particularly appreciated the protected environment where they could practice clinical skills under supervision before interviewing other patients in patient-centred clinical settings. Tutors appreciated an environment which eliminated tensions often present between teaching and service delivery. They enjoyed focussed teaching sessions especially if details of invited patients were known in advance and 'backup' resources were available. Patients enjoyed opportunities to contribute to clinical teaching.

Twelve tips for setting up an ambulatory care (outpatient) teaching centre.

The ambulatory care setting is becoming an increasingly important environment for clinical teaching. This reflects the changing focus of healthcare delivery with more procedures and patient treatment being delivered in this setting. Maximizing learning opportunities for students without compromising patient care has never provided a greater challenge. This paper shares 12 educational tips for developing an ambulatory care teaching centre where both students and patients benefit from a protected yet realistic clinical setting.