General practice pharmacists' implementation of advanced clinical assessment skills: a qualitative study of behavioural determinants.

BACKGROUND: The role of General Practice Clinical Pharmacists is becoming more clinically complex. Some are undertaking courses to develop their skillsets. AIM: To explore potential behavioural determinants influencing the implementation of skills gained from Advanced Clinical Examination and Assessment courses by General Practice Clinical Pharmacists. METHOD: This study used a qualitative methodology with theoretical underpinning. General Practice Clinical Pharmacists in the Scottish National Health Service, having completed an Advanced Clinical Examination and Assessment course, were invited for online dyadic (paired) interviews. Informed written consent was obtained. The interview schedule was developed using the Theoretical Domains Framework and piloted. Interviews were recorded, transcribed verbatim and analysed using a framework analysis. Ethics approval was obtained. RESULTS: Seven dyadic interviews were conducted. These included fourteen pharmacist participants from eight Health Boards. Three main themes were identified: 1. Factors influencing implementation of advanced clinical skills by pharmacists; 2. Social and environmental influences affecting opportunities for pharmacists in advanced clinical roles; 3. Perceptions of pharmacist professional identity for advanced practice roles. Nine sub-themes provided a depth of insight including; participants reporting courses allowed clinically autonomous practice; participants shared frustration around social and environmental factors limiting implementation opportunities; participants expressed a need for clarification of professional identify/roles within current contractual mechanisms to allow them to fully implement the skills gained. CONCLUSION: This work identified numerous behavioural determinants related to implementation of advanced clinical skills by pharmacists in general practice. Policy, and review of implementation strategies are urgently required to best utilise pharmacists with these skills.

Scotland's GP paediatric scholarship: an evaluation.

In a previous publication we described the implementation and early evaluation of general practice paediatric scholarships in Scotland. We suggested that it was too early to be able to determine whether this significant investment will produce a return for Scotland in terms of enhanced roles in providing, leading or developing children's services in primary care or at the primary care/secondary care interface. This paper presents the results of a survey of the impact of the scholarship for the first six cohorts of the scholarship (119 General Practitioners). The response rate was 76%. Of the 90 respondents, almost half (44) have developed roles or areas of special paediatric interest either within or out with the practice, or in three cases both within and out with the practice. A total of 37 (43%) of those that continue to work within general practice reported that they have developed areas of special interest of benefit to the practice. Qualitative analysis of free text questions suggested that scholars had benefited from their experience in terms of increased confidence in dealing with child health problems, developing links with secondary care colleagues, and personal gain with respect to role development. What is already known in this area: Changes in GP Training have been suggested in order to provide a workforce that can meet the needs of infants, children and young people. Studies have shown a positive impact of paediatric trainees and GP trainees learning together. Little attention has however been given to the potential to support trained GPs to develop their expertise in child health. What this work adds: Early evaluation of the Scottish Paediatric Scholarship suggested a high degree of satisfaction. This more robust evaluation suggests that almost half (44/90 respondents) have developed roles or areas of special paediatric interest either within or out with the practice, or in three cases both within and out with the practice. Suggestions for future work in this area: A longer follow-up supported by more rigorous qualitative evaluation would be beneficial in understanding to what extent, and how scholars have played an enhanced role in providing, leading or developing children's services in primary care, and what role the scholarship has played in realising this. In addition an assessment of value for money would be important to ensure that the significant investment in the scholarship by NHS Scotland has had demonstrable impact. Ethical statement: As an evaluation of a focused CPD programme, ethical approval was not considered to be necessary.

Improving the primary-secondary care interface in Scotland: a qualitative exploration of impact on clinicians of an educational complex intervention.

OBJECTIVES: To determine the impact on clinicians and any consequent influence on patient care of taking part in the bespoke interface-focused educational intervention. DESIGN: Qualitative design. SETTING: Primary and secondary care centres in NHS Highland health board area, Scotland. PARTICIPANTS: 33 urban-based clinicians (18 general practitioners and 15 hospital specialists) in NHS Highland, Scotland. INTERVENTION: An interface-focused educational intervention was carried out in primary and secondary care centres in NHS Highland health board area, Scotland. Eligible clinicians were invited to take part in the intervention which involved facilitated small group work, and use of a bespoke educational module. Subsequent one-to-one interviews explored the impact of the intervention. A standard thematic analysis was used, comprising an iterative process based on grounded theory. RESULTS: Key themes that emerged included fresh insights (in relation to those individuals and processes across the interface), adoption of new behaviours (eg, being more empowered to directly contact a colleague, taking steps to reduce the others workload and changes in professional approach) and changes in terms of communication (including a desire to communicate more effectively, with use of different modes and methods). CONCLUSION: The study highlighted key areas that may serve as useful outcomes for a large-scale randomised trial. Addressing issues identified in the study may help to improve interface relationships and benefit patient care.

Development of an interface-focused educational complex intervention.

BACKGROUND: In many countries, the medical primary-secondary care interface is central to the delivery of quality patient care. There is prevailing interest in developing initiatives to improve interface working for the benefit of health care professionals and their patients. AIM: To describe the development of an educational intervention designed to improve working at the primary-secondary care interface in NHS Scotland (United Kingdom) within the context of the Medical Research Council framework for the development and evaluation of complex interventions. METHODS: A primary-secondary care interface focused Practice-based Small Group Learning (PBSGL) module was developed building upon qualitative synthesis and original research. A 'meeting of experts' shaped the module, which was subsequently piloted with a group of interface clinicians. Reflections on the module were sought from clinicians across NHS Scotland to provide contextual information from other areas. FINDINGS: The PBSGL approach can be usefully applied to the development of a primary-secondary care interface-focused medical educational intervention.

Annual trainer peer-review: impact on educational practice and sense of community.

INTRODUCTION: The General Medical Council (GMC) requires all doctors to undertake annual appraisal for all roles for which they hold a licence to practise. General Practitioner (GP) educational supervisors (ES) in the North of Scotland have undertaken annual ES peer-appraisal since 2002 which focuses on their role as ES and is separate to GMC appraisal. AIM: To investigate whether participation in annual peer appraisal by GP trainers had affected their professional practice and sense of community Methods: Focus group methodology was utilised, supported by written reflective narratives. Thirty-five educational supervisors participated in three focus groups, moderated by educators from the north region of Scotland Deanery. The data included 35 narratives, flip charts and field notes. These were analysed using a thematic approach. RESULTS: Thirty-five trainers participated and themes emerged around four areas: organisational, process, outcomes and challenges. Due to its formative peer related features, peer appraisal was more valued than mandatory annual NHS appraisal. The value of a personally known peer as appraiser emerged as a major recurrent theme. Positive affective and effective outcomes were described by several participants. These included feeling more valued and confident. Some reported empowering and motivating effects to implement changes and tackle difficult situations. Some felt that appraisal added to the sense of community by developing new relationships and deepening existing ones. The risk of collusion was raised in several narratives and explored more deeply during focus group discussions. There was agreement that the process could be improved by making explicit what to do if concerns were identified. DISCUSSION: This study demonstrated the importance of peer appraisal for GP trainers, particularly in the context of locally based valued and trusted trainer groups. It affects their professional practice as educators and deepens their sense of community. This is of particular relevance to current discussions on medical educator appraisal in the context of re-approval and revalidation.

Scotland's GP Rural Fellowship: an initiative that has impacted on rural recruitment and retention.

CONTEXT: In Scotland 20% of the population live in a remote or rural area spread across 94% of the land mass that is defined as remote and rural. NHS Education for Scotland (NES), NHS Scotland's training and education body, works in partnership with territorial health boards and medical schools to address rural recruitment and retention through a variety of initiatives. The longest established of these is the GP Rural Fellowship, which has been in place since 2002. This article describes this program and reports on a survey of the output of the Fellowship from 2002 to 2013. THE RURAL FELLOWSHIP PROGRAM: The Fellowship is aimed at newly qualified GPs, who are offered a further year of training in and exposure to rural medicine. The Fellowship has grown and undergone several modifications since its inception. The current model involves co-funding arrangements between NES and participating boards, supporting a maximum of 12 fellows per year. The Health Boards' investment in the Fellowship is returned through the service commitment that the Fellows provide, and the funding share from NES allows Fellows to have protected educational time to meet their educational needs in relation to rural medicine. Given this level of funding support it is important that the outcome of the Fellowship experience is understood, in particular its influence on recruitment to and retention in general practice in rural Scotland. To address this need a survey of all previous rural Fellows was undertaken in the first quarter of 2014, including all Fellows that had undertaken the Fellowship between 2002-03 and 2012-13. A total of 69 GPs were recruited to the Fellowship in this period, of which 66 were able to be included in the survey. There was a response rate of 98% to the survey and 63 of those that responded (97%) were working currently in general practice, 53 of whom were doing so in Scotland. A total of 46 graduates of the Fellowship in the period surveyed (71%) were working in rural areas or accessible small towns in Scotland, 39 in substantive general practice roles (60%). LESSONS LEARNED: Scotland's GP Rural Fellowship program represents a successful collaboration between education and service, and the results of the survey reported in this article underline previously unpublished data that suggest that approximately three-quarters of graduates are retained in important roles in rural Scotland. It is unclear however whether the Fellowship confirms a prior intention to work in rural practice, or whether it provides a new opportunity through protected exposure. This will form the basis of further evaluation.

International medical graduates: a qualitative exploration of factors associated with success in the clinical skills assessment.

BACKGROUND: International medical graduates (IMGs) are known to have significantly lower first attempt pass rates at the clinical skills assessment examination (CSA) than UK graduates. Whilst much has been published concerning higher fail rates in this group, there has been very little exploration of factors associated with success. AIMS: This research aims to identify and explore factors associated with success in the CSA. METHOD: Telephone interviews with 10 IMGs who had passed the CSA on their first attempt were undertaken. Participants were current or recent (previous academic year) GP trainees in Scotland. Transcripts of the interviews were analysed by a thematic analysis approach. RESULTS: Six main themes emerged from the data analysis. These were insights into the challenges, a proactive approach, refining consultation skills, learning with UK graduates, valuing feedback and supportive relationships. Conclucions: This research adds the much-needed voice and experience of IMGs to a current area of uncertainty and challenge in medical education. It provides some insights into potential solutions to the issues and will be of interest to both trainees and those involved in their education.

Supporting educational supervisor development at the interface: evaluation of a pilot of PBSGL for faculty development.

Practice-based small group learning (PBSGL) is an established approach for continuing professional development (CPD) for GPs in Scotland. This paper describes an extension of the PBSGL approach to support the learning and development of educational supervisors from both hospital and general practice, working together in peer-facilitated small groups to address topic-specific, evidence-based educational modules. Four groups met on three occasions each and qualitative data were gathered from interviews with the facilitators and the participants. This was supplemented with observational data of the group process and function. Both GPs and consultants enjoyed the format and were very positive about the experience of working together in this way. Commitment to change educational practice and reported actual changes in practice were evident.

Sharing control of appointment length with patients in general practice: a qualitative study.

BACKGROUND: There is little published research into the impact, on both doctor and patient, of handing over responsibility for choosing appointment length to the patient. AIM: To investigate what impact giving patients control of their appointment length has on the patient and doctor experience. DESIGN AND SETTING: A qualitative study in a single medical practice in Inverness, Scotland. METHOD: Eligible patients making a 'routine' appointment were given a choice of appointment length (5, 10, 15, or 20 minutes). After the consultation, patients were invited to take part in a focused interview. Doctors were asked to keep an audio diary and their experience was explored further in a facilitated focus group. Data were analysed using a thematic analysis approach. RESULTS: Key themes that emerged for patients included the impact of the shift in power and the impact of introducing the issue of time. For doctors, important themes that emerged were impacts on the provider, on the doctor-patient relationship, and on the consultation. CONCLUSION: Giving patients greater responsibility for choosing appointment length may improve the experience for both doctors and patients.

Practice-based small group learning in GP specialty training.

INTRODUCTION: Practice-based small group learning (PBSGL) is an approach to continuing professional development (CPD) for general practitioners (GPs) that originated in Canada. It involves small groups of GPs who work through clinical modules. PBSGL is now an established method of learning in Scotland, found to be effective in GP, practice nurse and multi-professional cohorts. However, the effectiveness of PBSGL has not been examined in GP specialty training, where it is becoming widely employed. This research aimed to explore GP Specialty Trainees' (GPSTs') perspectives of the impact of PBSGL on curriculum needs, preparation for independent practice, and facilitator learning. METHODS: To avoid the risk of extrapolating assumptions from others who have used PBSGL as a learning strategy, this study adopted a qualitative approach, and conducted one-to-one interviews with 16 GPSTs from a range of Scottish deaneries and stages in training. Data took the form of verbatim transcripts, and the constant comparative technique from grounded theory was used to analyse the data, through the establishment of codes and categories. RESULTS: Findings were arranged in four main areas: • learning as a group was appreciated at this career stage, and group membership should consist of trainees at a similar career stage, as this supports psychological safety • PBSGL helped in locating a 'one best way' for future care planning, but was also used to find alternatives to trainees' current approaches • discussion during PBSGL helped GPSTs devise plans for how they would handle patients in the future • some facilitators moderated their involvement for the perceived benefit of the group. DISCUSSION AND CONCLUSION: Learning is experienced in a very unique way for GPSTs, and the views of the cohort are formed on the basis of the delicate stage in their career. Aiding the transition from structured education into independent practice is a more immediate need for GPSTs than curriculum needs.

Parental reasons for non-uptake of influenza vaccination in young at-risk groups: a qualitative study.

BACKGROUND: Uptake rates of influenza vaccination in young at-risk groups in primary care (UK) are known to be poor. AIM: To explore parental reasons for non-uptake of influenza vaccination in young at-risk groups. The study hypothesis was that exploration of parental reasons for non-uptake may reveal important barriers to an effective influenza vaccination programme. DESIGN AND SETTING: Thematic analysis of a questionnaire survey with interview follow-up at a single general practice in Inverness, Scotland. METHOD: Parents of children identified as being in an at-risk group for influenza vaccination but who had not received vaccination were sent questionnaires and offered the opportunity to take part in a follow-up interview. RESULTS: Several key themes emerged, including uncertainty about the indication for vaccination, issues of choice, challenges with access, lack of parental priority, and issues relating to health beliefs. CONCLUSION: Any attempt to improve the vaccination rate needs to address the range of decision-making processes undertaken by parents and children. Better and more tailored information and educational delivery to parents, patients, and healthcare providers may lead to an increase in the rates of influenza vaccination uptake in at-risk children. Access is a barrier described by some parents.