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Context: Patient–student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience. Methods: Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed. Results: Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty‐eight studies had a full‐text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient‐student relationship' contains the sub‐themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub‐themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'. Conclusions: LICs provide educational continuity allowing the creation of a trusting patient–student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes. Longitudinal Integrated Clerkships provide educational continuity, enabling trusting patient‐student relationships that lead students to become agents of change and enhance patient outcomes. [ABSTRACT FROM AUTHOR]

The authors explain how patient advocacy can be a reparative force to address fragmentation in healthcare systems through advances in the design of clinical education, national frameworks and clinical assessment. [ABSTRACT FROM AUTHOR]

A taskforce established by Medical Education asks readers to engage in discussion about how the journal and field can do better to ensure that health professional education publishing is inclusive of diverse knowledge and perspectives. [ABSTRACT FROM AUTHOR]

Objectives: Interprofessional education (IPE) aims to provide students with the opportunity to develop and demonstrate the team working behaviours and skills that will lead to positive patient outcomes. This systematic review aims to identify and critically appraise the assessment tools used after a pre‐licensure IPE intervention and provide guidance on which tool to use according to the focus of the intervention. Methods: In July 2019, the following electronic databases were searched: MEDLINE, ERIC, CINHAL, EMBASE and NEXUS website. All studies involving pre‐licensure health care students exposed to an IPE intervention and undertook an assessment measuring student knowledge, skills, behaviour, or change in organisational practice or a benefit to patients were included. Studies that used tools relying on self‐assessment only were excluded. Constructive alignment of the IPE intervention with the assessment was evaluated and quality assessment of the studies and critical appraisal of the validity evidence for the tools was undertaken. Results: From 9502 returned studies, 39 studies met the inclusion criteria and were analysed. These were rated as good in terms of methodological quality. Acquisition of knowledge was the most commonly assessed outcome, mainly with pre/post knowledge tests, followed by behaviour change, which was measured by a range of validated tools. Patient benefit was defined as change in clinical effectiveness, patient safety or patient satisfaction. Constructive alignment of the IPE aim with the assessment was limited due to issues with study reporting. Tools measuring behaviour change demonstrate mixed adherence to quality standards around reliability, validity and scales and scoring. Conclusions: Various methods have been used to identify change following IPE; however, choosing the most appropriate tool to support and align with the aim of the IPE intervention is crucial. We have critically appraised the available tools and offered an indication of their quality. This has informed the production of a decision aid to support the selection of the appropriate IPE assessment tool depending on the purpose of the intervention. More studies using these tools in rigorous study designs are required to substantiate the evidence base. The authors examine the methods used to identify changes following Interprofessional Education, developing a decision‐aid to best align tools with the aim of IPE interventions. [ABSTRACT FROM AUTHOR]

Bystander action has been proposed as a promising intervention to tackle workplace bullying, however there is a lack of in-depth qualitative research on the direct experiences of bystanders. In this paper, we developed a more comprehensive definition of bullying bystanders, and examined first person accounts from healthcare professionals who had been bystanders to workplace bullying. These perspectives highlighted factors that influence the type and the extent of support bystanders may offer to targets. Semi-structured telephone interviews were conducted with 43 healthcare professionals who were working in the UK, of which 24 had directly witnessed bullying. The data were transcribed and analysed using Thematic Analysis. The analysis identified four themes that describe factors that influence the type and extent of support bystanders offer to targets of bullying: (a) the negative impact of witnessing bullying on bystanders, (b) perceptions of target responsibility, (c) fear of repercussions, and (d) bystander awareness. Our findings illustrate that, within the healthcare setting, bystanders face multiple barriers to offering support to targets and these factors need to be considered in the wider context of implementing bystander interventions in healthcare settings. [ABSTRACT FROM AUTHOR]

Almoghirah et al. reflect on the many variables that influence individual performance within collaborative work, offering insight into the power of personalised, subjective and contextualised assessment and feedback. [ABSTRACT FROM AUTHOR]

The article offers information on topics related to international medical graduates (IMGs). Topics mentioned include the importance of IMG, the support of the National Health Service (NHS) Trust in the project that aims to help IMG, and the services for the IMGs. Also mentioned are the assessment for medical personnel, the physician training, and the importance of medical personnel retention rates.

Objective To identify the perception of positive feedback (PF) and negative feedback (NF) provided by trainers in the operating theatre on surgical trainees' confidence and well-being. Design Narrative interview study. Setting Twelve hospitals that form part of one deanery within the UK. Participants Maximum variation sampling of 15 higher general surgical trainees provided insight into how PF and NF from trainers in the operating theatre affect confidence and well-being. Methods Narrative telephone interviews were conducted with general surgical trainees between April and June 2016. All interviews were recorded, transcribed and anonymised. Transcriptions were analysed using the five-step framework analysis by two independent researchers. Results Fifteen trainees (age 28-38 years) were interviewed (median interview time: 29 min). Thematic framework analysis identified nine themes within the data. PF, which included corrective feedback, helped the trainees to relax and seemed to enhance their operative performance. All trainees reported significant and unjustified NF, some of which would be defined as undermining and bullying. Many believed this to have a negative impact on their training with minimal educational benefit. Many trainees felt NF adversely affected their performance in the operating theatre with some expressing a wish to leave the profession as a consequence. Conclusion Both PF and NF exist in the operating theatre. Both have an important influence on the trainee, their performance and career. PF, if specific, helped aid progression of learning, increased motivation and performance of surgical trainees. In contrast, NF was perceived to have detrimental effects on trainees' performance and their well-being and, in some, introduced a desire to pursue an alternative career. [ABSTRACT FROM AUTHOR]

Background: International medical graduates working in the UK are more likely to be censured in relation to fitness to practise compared to home graduates. Performance on the General Medical Council's (GMC's) Professional and Linguistic Assessments Board (PLAB) tests and English fluency have previously been shown to predict later educational performance in this group of doctors. It is unknown whether the PLAB system is also a valid predictor of unprofessional behaviour and malpractice. The findings would have implications for regulatory policy.Methods: This was an observational study linking data relating to fitness to practise events (referral or censure), PLAB performance, demographic variables and English language competence, as evaluated via the International English Language Test System (IELTS). Data from 27,330 international medical graduates registered with the GMC were analysed, including 210 doctors who had been sanctioned in relation to at least one fitness to practise issue. The main outcome was risk of eventual censure (including a warning).Results: The significant univariable educational predictors of eventual censure (versus no censures or referrals) were lower PLAB part 1 (hazard ratio [HR], 0.99; 95% confidence interval, 0.98 to 1.00) and part 2 scores (HR, 0.94; 0.91 to 0.97) at first sitting, multiple attempts at both parts of the PLAB, lower IELTS reading (HR, 0.79; 0.65 to 0.94) and listening scores (HR, 0.76; 0.62 to 0.93) and higher IELTS speaking scores (HR, 1.28; 1.04 to 1.57). Multiple resits at either part of the PLAB and higher IELTS speaking score (HR, 1.49; 1.20 to 1.84) were also independent predictors of censure. We estimated that the proposed limit of four attempts at both parts of the PLAB would reduce the risk in this entire group by only approximately two censures per 5 years in this group of doctors.Conclusions: Making the PLAB, or any replacement assessment, more stringent and raising the required standards of English reading and listening may result in fewer fitness to practice events in international medical graduates. However, the number of PLAB resits permitted would have to be further capped to meaningfully impact the risk of sanctions in this group of doctors. [ABSTRACT FROM AUTHOR]

Context Many health services and systems rely on the contribution of international medical graduates ( IMGs) to the workforce. However, concern has grown around their regulation and professional practice. There is a need, in the absence of strong evidence and a robust theoretical base, for a deeper understanding of the efficacy of interventions used to support IMGs' transition to their host countries. This study seeks to explore and synthesise evidence relating to interventions developed for IMGs. It aims to provide educators and policy makers with an understanding of how interventions should be developed to support IMGs in their transition to the workplace, particularly looking to identify how and why they are effective. Methods The realist synthesis involved an initial systematic search of the literature for the period January 1990 to April 2015. Secondary searches were conducted throughout the review in order to inform and test the developing programme theory. The context, mechanism and outcome data were extracted from all sources meeting the inclusion criteria. Fourteen case studies were included to further aid theory refinement. Results Sixty-two articles were identified, describing diverse interventions of varying intensity. A further 26 articles were identified through a secondary search. The findings illustrate that, alongside a developed programme, ongoing support and cultural awareness at organisational and training levels are crucial. Individual differences must also be taken into consideration. This will ensure that IMGs engage in transformative learning, increase their levels of self-efficacy and cultural health capital, and reduce feelings of stress and anxiety. These factors will have an impact on work, interactions and cultural adjustment. Conclusions Organisational, training and individual contexts all play a role in IMGs' adjustment during the transition process. Establishing ongoing support is critical. A list of recommendations for implementation is given. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the difficulties Japanese female doctors face in continuing professional practice. Design: A qualitative study using the Kawakita Jiro method. Setting: A survey conducted in 2011 of 13 private Japanese medical school alumni associations. Participants: 359 female doctors. Primary outcome measures: Barriers of balancing work and gender role. Results: The female doctors reported that professional practice was a struggle with long working hours due to a current shortage of doctors in Japan. There was also a severe shortage of childcare facilities in the workplace. Some women appeared to have low confidence in balancing the physician's job and personal life, resulting in low levels of professional pursuit. There appeared to be two types of stereotypical gender roles, including one expected from society, stating that "child rearing is a woman's job", and the other perceived by the women themselves, that some women had a very strong desire to raise their own children. Male doctors and some female doctors who were single or older were perceived to be less enthusiastic about supporting women who worked while raising children because these coworkers feared that they would have to perform additional work as a result of the women taking long periods of leave. Conclusions: Important factors identified for promoting the continuation of professional practice among female doctors in Japan were the need to improve working conditions, including cutting back on long working hours, a solution to the shortage of nurseries, a need for the introduction of educational interventions to clarify professional responsibilities, and redefinition of the gender division of labour for male and female doctors. In addition, we identified a need to modernise current employment practices by introducing temporary posts to cover maternity leave and introducing flexible working hours during specialist training, thus supporting and encouraging more women to continue their medical careers. [ABSTRACT FROM AUTHOR]

Objective: To explore the effects of the UK Working Time Regulations (WTR) on trainee doctors' experience of fatigue. Design: Qualitative study involving focus groups and telephone interviews, conducted in Spring 2012 with doctors purposively selected from Foundation and specialty training. Final compliance with a 48 h/week limit had been required for trainee doctors since August 2009. Framework analysis of data. Setting: 9 deaneries in all four UK nations; secondary care. Participants: 82 doctors: 53 Foundation trainees and 29 specialty trainees. 36 participants were male and 46 female. Specialty trainees were from a wide range of medical and surgical specialties, and psychiatry. Results: Implementation of the WTR, while acknowledged as an improvement to the earlier situation of prolonged excessive hours, has not wholly overcome experience of long working hours and fatigue. Fatigue did not only arise from the hours that were scheduled, but also from an unpredictable mixture of shifts, work intensity (which often resulted in educational tasks being taken home) and inadequate rest. Fatigue was also caused by trainees working beyond their scheduled hours, for reasons such as task completion, accessing additional educational opportunities beyond scheduled hours and staffing shortages. There were also organisational, professional and cultural drivers, such as a sense of responsibility to patients and colleagues and the expectations of seniors. Fatigue was perceived to affect efficiency of skills and judgement, mood and learning capacity. Conclusions: Long-term risks of continued stress and fatigue, for doctors and for the effective delivery of a healthcare service, should not be ignored. Current monitoring processes do not reflect doctors' true working patterns. The effectiveness of the WTR cannot be considered in isolation from the culture and context of the workplace. On-going attention needs to be paid to broader cultural issues, including the relationship between trainees and seniors. [ABSTRACT FROM AUTHOR]

Background: Historically, overseas-qualified doctors have been essential for meeting service needs in the UK National Health Service (NHS). However, these doctors encounter many cultural differences, in relation to training, the healthcare system and the doctor-patient relationship and training. Aim: To examine whether Hofstede's cultural model may help us understand the changes doctors from other countries experience on coming to work in the UK, and to identify implications for supervisors and clinical teams. Method: Telephone interviews were conducted with overseas medical graduates before starting work as a Foundation Year One (F1) doctor, followed up after four months and 12 months; and with educational supervisors. Data were analysed using a confirmatory thematic approach. Results: Sixty-four initial interviews were conducted with overseas doctors, 56 after four months, and 32 after 12 months. Twelve interviews were conducted with educational supervisors. The changes doctors experienced related particularly to Hofstede's dimensions of power distance (e.g. in relation to workplace hierarchies and inter-professional relationships), uncertainty avoidance (e.g. regarding ways of interacting) and individualism-collectivism (e.g., regarding doctor-patient/family relationship; assertiveness of individuals). Conclusion: Hofstede's cultural dimensions may help us understand the adaptations some doctors have to make in adjusting to working in the UK NHS. This may promote awareness and understanding and greater 'cultural competence' amongst those working with them or supervising them in their training. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: To examine the prevalence and impact of bullying behaviours between staff in the National Health Service (NHS) workplace, and to explore the barriers to reporting bullying. Design: Cross-sectional questionnaire and semi-structured interview. Setting: 7 NHS trusts in the North East of England. Participants: 2950 NHS staff, of whom 43 took part in a telephone interview. Main outcome measures: Prevalence of bullying was measured by the revised Negative Acts Questionnaire (NAQ-R) and the impact of bullying was measured using indicators of psychological distress (General Health Questionnaire, GHQ-12), intentions to leave work, job satisfaction and self-reported sickness absence. Barriers to reporting bullying and sources of bullying were also examined. Results: Overall, 20% of staff reported having been bullied by other staff at least 'now and then' and 43% reported having witnessed bullying in the last 6 months. Male staff and staff with disabilities reported higher levels of bullying. There were no overall differences due to ethnicity, but some differences were detected on several negative behaviours. Bullying and witnessing bullying were associated with lower levels of psychological health and job satisfaction, and higher levels of intention to leave work. Managers were the most common source of bullying. Main barriers to reporting bullying were the perception that nothing would change, not wanting to be seen as a trouble-maker, the seniority of the bully and uncertainty over how policies would be implemented and bullying cases managed. Data from qualitative interviews supported these findings and identified workload pressures and organisational culture as factors contributing to workplace bullying. Conclusions: Bullying is a persistent problem in healthcare organisations which has significant negative outcomes for individuals and organisations. [ABSTRACT FROM AUTHOR]

Background: There is evidence that graduates of different medical schools vary in their preparedness for their first post. In 2003 Goldacre et al. reported that over 40% of UK medical graduates did not feel prepared and found large differences between graduates of different schools. A follow-up survey showed that levels of preparedness had increased yet there was still wide variation. This study aimed to examine whether medical graduates from three diverse UK medical schools were prepared for practice. Methods: This was a qualitative study using a constructivist grounded theory approach. Prospective and crosssectional data were collected from the three medical schools. A sample of 60 medical graduates (20 from each school) was targeted. They were interviewed three times: at the end of medical school (n = 65) and after four (n = 55) and 12 months (n = 46) as a Year 1 Foundation Programme doctor. Triangulated data were collected from clinicians via interviews across the three sites (n = 92). In addition three focus groups were conducted with senior clinicians who assess learning portfolios. The focus was on identifying areas of preparedness for practice and any areas of lack of preparedness. Results: Although selected for being diverse, we did not find substantial differences between the schools. The same themes were identified at each site. Junior doctors felt prepared in terms of communication skills, clinical and practical skills and team working. They felt less prepared for areas of practice that are based on experiential learning in clinical practice: ward work, being on call, management of acute clinical situations, prescribing, clinical prioritisation and time management and dealing with paperwork. Conclusions: Our data highlighted the importance of students learning on the job, having a role in the team in supervised practice to enable them to learn about the duties and responsibilities of a new doctor in advance of starting work. [ABSTRACT FROM AUTHOR]

Objectives: To identify what healthcare organisations, including medical regulators, can do to address the issues and concerns faced by overseas-qualified doctors when moving to the UK. Methods: Qualitative interviews were conducted with sixty-six doctors who had qualified outside the UK and who were entering the first year of the UK Foundation Programme (FY1, equivalent to the intern year). Doctors were inter-viewed three times at different points in that year. In addition twelve telephone interviews were conducted with educational supervisors. A grounded theory approach was used to analyse the findings. Results: Issues and concerns were found to relate to: practical and logistical difficulties; gaps in declarative knowledge relevant to the UK, for example, use of equipment and drug names; structural differences, for example, organisational elements of working in the NHS, and differences in the relational aspects of professional work and clinical care, stemming from training in different models of healthcare. Conclusions: Agencies at different levels - government, regulator and employer - have a role to play in supporting overseas-doctors in their transition, and it is suggested that a co-ordinated approach would have benefits for doctors and patients. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Questionnaires provide a useful and versatile tool for new and occasional researchers, and can be applied to a wide range of topics. This paper provides simple guidance on some of the potential pitfalls in developing and running a questionnaire study, and how to avoid them. Each tip is illustrated with a real-life example from the development of a UK-wide questionnaire survey of trainee doctors and their educational supervisors. [ABSTRACT FROM AUTHOR]