Carol Davies

Preparedness for practice : the perceptions of medical graduates and clinical teams

Background: Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school. Aims: To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members. Method: An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts. Results: The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites. Conclusions: New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.

Newly qualified doctors’ perceptions of informal learning from nurses: implications for interprofessional education and practice

Abstract Newly qualified doctors spend much of their time with nurses, but little research has considered informal learning during that formative contact. This article reports findings from a multiple case study that explored what newly qualified doctors felt they learned from nurses in the workplace. Analysis of interviews conducted with UK doctors in their first year of practice identified four overarching themes: attitudes towards working with nurses, learning about roles, professional hierarchies and learning skills. Informal learning was found to contribute to the newly qualified doctors’ knowledge of their own and others’ roles. A dynamic hierarchy was identified: one in which a “pragmatic hierarchy” recognising nurses’ expertise was superseded by a “normative structural hierarchy” that reinforced the notion of medical dominance. Alongside the implicit learning of roles, nurses contributed to the explicit learning of skills and captured doctors’ errors, with implications for patient safety. The findings are discussed in relation to professional socialisation. Issues of power between the professions are also considered. It is concluded that increasing both medical and nursing professions’ awareness of informal workplace learning may improve the efficiency of education in restricted working hours. A culture in which informal learning is embedded may also have benefits for patient safety.

Implementing IT in NHS hospitals - internal barriers to technological advancement

There remains an ambitious objective to develop high specification Hospital Information Systems within the UK National Health Service, but progress has been slow. Successful implementation requires both effective project management and process change. The literature already acknowledges the difficult environment that healthcare IT projects operate within. This paper uses a longitudinal case study to examine the presence or absence of critical success factors in an NHS Hospital, for both the implementation and operationalisation of technology. The findings suggest that external factors are not the only reason for the slow introduction and limited impact of new technology. Internal barriers that significantly limit the implementation process include an unsupportive organisation structure, irreconcilable differences in stakeholder requirements, the low status of the project team, a poor understanding of process management issues and organisation politics.

The National Traumatic Brain Injury Study: Assessing Outcomes across Settings

This paper describes the solution adopted by a research team to the problem of evaluating rehabilitation outcomes across 12 differing traumatic brain injury services in England. A total of 507 subjects and their families received first and follow-up interviews. A wide range of data were collected, including medical and demographic data, hours and nature of rehabilitation, and details of pre-injury lifestyle. Subjects were monitored for up to 3 years from entry into the study. The process of change was charted in a series of interviews in which subjects and carers were asked to describe current problems and strengths. Responses were classified and quantified. The resulting information was used in a number of different ways: To examine whether problems resolved; to examine the range of impairments, disabilities and more general problems, and changes over time, and to examine reported problems in the context of individual experience in order to measure the response of communities. Although existing objective...

Clinical governance and operations management methodologies

The clinical governance mechanism, introduced since 1998 in the UK National Health Service (NHS), aims to deliver high quality care with efficient, effective and cost-effective patient services. Scally and Donaldson recognised that new approaches are needed, and operations management techniques comprise potentially powerful methodologies in understanding the process of care, which can be applied both within and across professional boundaries. This paper summarises four studies in hospital Trusts which took approaches to improving process that were different from and less structured than business process re-engineering (BPR). The problems were then amenable to change at a relatively low cost and short timescale, producing significant improvement to patient care. This less structured approach to operations management avoided incurring overhead costs of large scale and costly change such as new information technology (IT) systems. The most successful changes were brought about by formal tools to control quantity, content and timing of changes.

Paediatric home care for acute illness: I. GPs’ and hospital‐at‐home staff views

Previous studies of general practitioner views of paediatric home care have presented a rather negative view of such services. This study examines GPs’, nurses’ and managers’ views of a new, acute paediatric hospital‐at‐home nursing service in Rugby. Methods used are qualitative and quantitative questionnaires and interviews, including Likert‐type scales and open questions. Contrary to the mixed and somewhat negative findings of previous studies, this study reports positive views on the impact of hospital‐at‐home in Rugby, in terms of acceptability and impact on the roles and responsibilities of GPs.

Paediatric home care for acute illness: III. Parental views

Parental satisfaction with paediatric home care has previously been found to be high and the results presented here confirm this finding. This study is unique in that a well defined population from one geographical area was studied before and after the introduction of the new home care service. Referrers included general practitioners, doctors in emergency care and out‐patient clinics, referring children for a wide range of acute conditions. Compared with hospital admission only half the number of adverse effects on children and families were reported by parents. Interest has been increasing in alternative service provision to prevent or reduce paediatric hospital admissions to avoid adverse effects on children and families. This study examined the views of parents experiencing hospital at home compared with hospital referral between 1999 and 2001 across the whole spectrum of acute clinical conditions. Hospital at home was the preferred service for a wide range of illnesses. Parents and carers identified extension of hospital at home to 24‐hour cover as a future preference. Parental preference for paediatric hospital at home for acute illness was confirmed.

Quality of care: replacing or removing ineffective services

Clinicians have the important quality assurance task of implementing changes to treatments offered, on the basis of clinical effectiveness. Problems seem to arise when evidence emerges, casting doubt on the effectiveness of existing treatments, that require services to be substituted or reduced. In such cases, change is often slow and inconsistent across wide geographic areas. This study identifies factors that influence the success or failure of attempts to replace or reduce ineffective treatments. Success factors include the need for external support for a change, the development of training and education for staff, transitional resourcing and multi‐agency planning. Conflicting evidence, poor implementation planning, a lack of experience and internal organization issues were generally associated with failure.