Ronald MacVicar

Requesting a commitment to change: Conditions that produce behavioral or attitudinal commitment

There is a lack of clarity in the conceptualization of commitment underlying the commitment to change (CTC) procedure used by organizers of continuing education in the health professions. This article highlights the two distinct conceptualizations of commitment that have emerged in the literature outside health care education and practice. The distinction is important because different antecedent conditions produce different types and dimensions of commitment. This article goes on to explore the antecedents of behavioral and attitudinal commitment and illustrates how different types of commitment may have been produced in previous CTC studies. As a result, the article also demonstrates the need for clarity in the conceptualization of commitment, especially to guide empirical research into the nature and strength of commitment produced by the variety of CTC strategies. Such research is relevant in increasing our understanding of how and why CTCs are able to influence practice change.

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.

Modern management of splenic trauma

#### Summary points Trauma is a major cause of morbidity and mortality; in the developed world, road traffic accidents are one of the leading causes. Up to 45% of patients with blunt abdominal trauma will have a splenic injury,1 which may require urgent operative management, angioembolisation, or non-operative management in the form of active observation. The management of splenic injuries has evolved over the past three decades with the realisation of the importance of the spleen in immunological defence against encapsulated organisms and a better understanding of the role of non-operative management of splenic injuries. Such management has been aided by better diagnostic and monitoring facilities and by advances in interventional radiology. This article aims to review the best available evidence for the management of patients with blunt splenic trauma. #### Sources and selection criteria We did a literature review by searching the Medline database to locate English language articles, using the terms “blunt splenic injury,” “spleen,” “trauma,” “investigation,” “computed tomography,” “splenic angioembolisation,” and “non-operative management” and then by carrying out a hand search of reference lists of …

The practice-based small group learning approach: Making evidence-based practice come alive for learners

This paper reports the study of a pilot learning programme for the Continuing Professional Development of Practice Nurses (PNs) in Scotland. Two PN groups used the practice-based small group (PBSG) approach to learning, which is designed to encourage learning relevant to patient problems faced in day-to-day practice. Learners kept a log of their experiences of engaging in PBSG learning for three consecutive meetings. Data was also collected through interviews. The findings detail the motivation for joining the PBSGs, group dynamics and the development of cohesion, factors influencing participation in group-discussions and the nature of learning that took place in the groups. PNs from both groups reported that discussions led to habitual practices being challenged but without hostility, and that various sources of information were considered. The suitability of PBSG learning to promote evidence-based nursing practice is discussed.

Practice-based Small Group Learning: How health professionals view their intention to change and the process of implementing change in practice

Commitment-to-change (CTC) strategies used as part of Continuing Professional Development (CPD) programmes have been found to influence changes in the clinical practice of health professionals. However, there is an unquestioned usage of the term ‘commitment’ to describe the statements made by learners specifying the changes they intend to make following CPD programmes. The Practice-based Small Group Learning (PBSGL) programme is one approach to the CPD of health professionals that includes a CTC instrument. This study reports on a pilot PBSGL programme in Scotland, which composed of mixed groups of General Practitioners (GPs) and Practice Nurses (PNs), as well as PN-only groups. Using qualitative methods, the study examines the meaning that learners ascribe to their statements of intention to introduce changes in their practice. It reveals that for some participants commitment is too strong a word to describe their intention. Nevertheless, others did feel that they were committing to the changes that they identified at PBSGL meetings. This study also explores the factors that influenced the decision of PBSGL participants to introduce practice changes, and the process of implementing change in clinical practice.

The Practice-based Small Group Learning Programme: Experiences of learners in multi-professional groups

This study describes the experiences of General Practitioners (GPs) and Practice Nurses (PNs) as they came together and engaged in the Practice-based Small Group Learning (PBSGL) programme. Based on principles of adult and small group learning, PBSGL, which was developed in Canada, was used for the first time for the Continuing Professional Development (CPD) of multi-professional groups in the UK. The findings detail the main reasons GPs and PNs participated in PBSGL, the nature of interaction and development of cohesion in the groups, factors influencing contribution to discussions, the learning process, and outcomes for learners. Respect shown for different roles and perspectives enabled participants to be open about gaps in their knowledge and to ask questions. A mutual keenness to understand the perspectives of and learn from the other profession emerges as a key ingredient for learners to feel that their learning needs were met. The learning process in the groups came close to transformative learning – there were changes in perspectives, acquisition of new knowledge and increased self-esteem. The appropriateness of the PBSGL approach for the CPD of mixed groups of GPs and PNs is discussed.

What are the CPD needs of GPs working in areas of high deprivation? Report of a focus group meeting of ‘GPs at the Deep End’

(2015). What are the CPD needs of GPs working in areas of high deprivation? Report of a focus group meeting of ‘GPs at the Deep End’. Education for Primary Care: Vol. 26, No. 3, pp. 139-145.

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

Abstract 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.

Scotland’s GP paediatric scholarship: an evaluation

Abstract 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.

Development of an interface-focused educational complex intervention

Abstract 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.