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Objectives: To investigate whether and how structured feedback sessions can increase rates of appropriate antimicrobial prescribing by junior doctors., Methods: This was a mixed-methods study, with a conceptual orientation towards complexity and systems thinking. Fourteen junior doctors, in their first year of training, were randomized to intervention (feedback) and 21 to control (routine practice) groups in a single UK teaching hospital. Feedback on their antimicrobial prescribing was given, in writing and via group sessions. Pharmacists assessed the appropriateness of all new antimicrobial prescriptions 2 days per week for 6 months (46 days). The mean normalized prescribing rates of suboptimal to all prescribing were compared between groups using the t-test. Thematic analysis of qualitative interviews with 10 participants investigated whether and how the intervention had impact., Results: Data were collected on 204 prescriptions for 166 patients. For the intervention group, the mean normalized rate of suboptimal to all prescribing was 0.32 ± 0.36; for the control group, it was 0.68 ± 0.36. The normalized rates of suboptimal prescribing were significantly different between the groups (P = 0.0005). The qualitative data showed that individuals' prescribing behaviour was influenced by a complex series of dynamic interactions between individual and social variables, such as interplay between personal knowledge and the expectations of others., Conclusions: The feedback intervention increased appropriate prescribing by acting as a positive stimulus within a complex network of behavioural influences. Prescribing behaviour is adaptive and can be positively influenced by structured feedback. Changing doctors' perceptions of acceptable, typical and best practice could reduce suboptimal antimicrobial prescribing., (© The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Touch mediates health professionals’ interactions with patients. Different professionals have reported their practices but what is currently lacking is a well-theorized, interprofessional synthesis. We systematically searched eight databases, identified 41 studies in seven professions—nursing (27), medicine (4), physiotherapy (5), osteopathy (1), counseling (2), psychotherapy (1), dentistry (1)—and completed a meta-ethnographic line-of-argument synthesis. This found that touch is caring, exercises power, and demands safe space. Different professions express care through the medium of touch in different ways. They all, however, expect to initiate touch rather than for patients to do so. Various practices negotiate boundaries that define safe spaces between health care professions and patients. A metaphor—the waltz—integrates the practice of touch. Health care professionals connect physically with patients in ways that form strong relationships between them while “dance steps” help manage the risk that is inherent in such an intimate form of connection. [ABSTRACT FROM AUTHOR]

Introduction: Recent National Institute for Health and Care Excellence (NICE) guidelines aim to improve intravenous (IV) fluid prescribing for children, but existing evidence about how and why fluid prescribing errors occur is limited. Studying this can lead to more effective implementation, through education and systems design. Aims: Methods: Mixed methods observational study which analysed critical incident reports relating to IV fluid prescribing errors in children aged 0–16, occurring between 2011 and 2015 in UK secondary care. We quantified characteristics and types of errors, then qualitatively analysed narrative descriptions, identifying underlying contributing factors. Results: In the 40 incidents analysed, principal types of errors were incorrect rate of fluids, inappropriate choice of solution, and incorrect completion of prescription charts. Prescribers had to negotiate complex patients, interactions with other practitioners and teams, and challenging work environments; errors resulted from these inter-related contributing factors. Conclusions: This study highlights the diverse range and complex nature of IV fluid prescribing errors reported in practice. While these findings have the inherent limitations of critical incident reports, they point to areas of potential improvement in education and systems design. Practising prescribing in context, inducting doctors within the many specialties who contribute to care of children, and educating them in joint working with nurses and pharmacists could help reduce errors. [ABSTRACT FROM AUTHOR]

Context Learning outcomes for residency training are defined in competency frameworks such as the Can MEDS framework, which ultimately aim to better prepare residents for their future tasks. Although residents' training relies heavily on learning through participation in the workplace under the supervision of a specialist, it remains unclear how the Can MEDS framework informs practice-based learning and daily interactions between residents and supervisors. Objectives This study aimed to explore how the Can MEDS framework informs residents' practice-based training and interactions with supervisors. Methods Constructivist grounded theory guided iterative data collection and analyses. Data were collected by direct observations of residents and supervisors, combined with formal and field interviews. We progressively arrived at an explanatory theory by coding and interpreting the data, building provisional theories and through continuous conversations. Data analysis drew on sensitising insights from communities of practice theory, which provided this study with a social learning perspective. Results Can MEDS roles occurred in an integrated fashion and usually remained implicit during interactions. The language of Can MEDS was not adopted in clinical practice, which seemed to impede explicit learning interactions. The Can MEDS framework seemed only one of many factors of influence in practice-based training: patient records and other documents were highly influential in daily activities and did not always correspond with Can MEDS roles. Additionally, the position of residents seemed too peripheral to allow them to learn certain aspects of the Health Advocate and Leader roles. Conclusions The Can MEDS framework did not really guide supervisors' and residents' practice or interactions. It was not explicitly used as a common language in which to talk about resident performance and roles. Therefore, the extent to which Can MEDS actually helps improve residents' learning trajectories and conversations between residents and supervisors about residents' progress remains questionable. This study highlights the fact that the reification of competency frameworks into the complexity of practice-based learning is not a straightforward exercise. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 1161-1173 Context General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory. Methods We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings. Results Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned 'know that' into 'know how'. Conclusions General practice must be expert in ensuring patients are well cared for 'by proxy' and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved. [ABSTRACT FROM AUTHOR]

This review examines the extent to which undergraduate prescribing education prepares graduates for the complexities of prescribing in the workplace context. In order to prescribe safely, it is important for medical students to acquire prescribing expertise. We have developed a theoretical model, based on theories of expertise development, which acknowledges the inherent complexity of the task itself, the social context and the relationship between the two. We have examined the empirical evidence on educational interventions for prescribing by reviewing the extent to which the interventions acknowledge the different components of our theoretical model. Fifteen empirical studies met our inclusion criteria and were reviewed in detail. All the studies were conducted between 2002 and 2010, six were controlled trials, six were before and after studies and three were prospective observational studies. We found that most studies focused on improving and evaluating students' knowledge and skills, although they used different approaches to doing so. These aspects of prescribing only constitute a small part of our theoretical model of prescribing expertise. Other important components, such as social context, metacognition and training transfer, were neglected. We suggest that educational interventions need to account for the integrated nature of learning to prescribe and take a more contextualized approach which considers the task as a whole, rather than isolated constituent parts. In doing so, prescribing education could equip graduates with the necessary expertise to judge and respond to situations, enabling them to prescribe safely, or seek the help to do so, in the unpredictable and complex context of workplaces. [ABSTRACT FROM AUTHOR]

Whilst much is debated about the importance of experiential learning in curriculum development, the concept only becomes effective if it is applied in an appropriate way. We believe that this effectiveness is directly related to a sound understanding of the theory, supporting the learning. The purpose of this article is to introduce readers to the theories underpinning experiential learning, which are then expanded further in an AMEE Guide, which considers the theoretical basis of experiential learning from a social learning, constructionist perspective and applies it to three stages of medical education: early workplace experience, clerkships and residency. This article argues for the importance and relevance of experiential learning and addresses questions that are commonly asked about it. First, we answer the questions 'what is experiential learning?' and 'how does it relate to social learning theory?' to orientate readers to the principles on which our arguments are based. Then, we consider why those ideas (theories) are relevant to educators - ranging from those with responsibilities for curriculum design to 'hands-on' teachers and workplace supervisors. The remainder of this article discusses how experiential learning theories and a socio-cultural perspective can be applied in practice. We hope that this will give readers a taste for our more detailed AMEE Guide and the further reading recommended at the end of it. [ABSTRACT FROM AUTHOR]

Background: The dynamics of effective teaching consultations need to be better understood. Aim: Find from medical students, patients and doctors how to optimize learning in ambulatory consultations. Methods: Patients and students independently gave semi-structured exit interviews after 25 ambulatory teaching consultations during a clinical attachment set up experimentally to strengthen students' ambulatory learning. The results of an abbreviated grounded theory analysis were checked in three focus group discussions with teachers and students. Results: Patients and students identified strongly with one another and benefited from teaching consultations in parallel ways yet defaulted to passive roles. Patients deferred to professional expertize whilst students were uncertain what was expected of them, feared harming patients and feared being showed up as ignorant. The educational value of consultations was determined by doctors' ability to promote student-patient interaction. Conclusions: In the most effective teaching consultations, doctors promoted a level of participation that realized patients' and students' mutual sense of responsibility by orientating them to one another, creating conditions for them to interact, promoting and regulating discourse, helping students to perform practical tasks and debriefing them afterwards. Those broad conclusions translate into 18 practical recommendations for supervising a medical student in an outpatient clinic or surgery. [ABSTRACT FROM AUTHOR]

The article presents an over view of dome of the best methods, including the use of portfolios, which medical school teachers can use to help their students become more reflective. A discussion of the benefits and need of being a good communicator when being employed as a physician is presented. Regulations in Great Britain which ensure that British doctors make reflection a critical foundation of their lifelong learning are discussed. The benefits of reflection in a medical education are examined. INSET: Teaching tips.

Aim: Compare how different researchers performed in screening for informative evidence about medical education. Method: Six researchers with three different levels of involvement in a systematic literature review screened articles by title and (where available) abstract, and then by reading articles they had selected in full text. The reference standard was a consensus decision to include or exclude the article in the final analysis, whose results are published elsewhere. Results: The single screener most involved in the literature search, who was also the most junior member of the topic review group, achieved a sensitivity approaching 100% and a specificity of 98-100% for informative articles. She far outperformed the other researchers, all of whom had as much or more topic knowledge and greater research experience. Conclusion: It was not possible to improve on the performance of the single motivated and capable primary screener and trying to do so increased the number of uninformative articles retrieved. One interpretation is that the primary searcher was more practiced and focused on the task than her more senior colleagues, yet they tended to become worse rather than better with practice. The fact that a well informed but relatively naïve person consistently outperformed her more "expert" colleagues might suggest an alternative explanation: Given the patchy standard and qualitative nature of the evidence, perhaps experts found it harder than a novice to make reliable choices, in which case their unreliable performance reflects the nature of present day education evidence. This case study illustrates the value of quality assuring the article selection process. Given the amount of disagreement uncovered by the study, we suggest that consensus between reviewers is an important reference standard against which the performance of any single primary screener should be checked. [ABSTRACT FROM AUTHOR]

Objective To develop a model linking the processes and outcomes of workplace learning. Methods We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students. Results To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves ‘participation in practice’, which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning. Conclusions The core condition for clinical workplace learning is ‘supported participation’, the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of ‘self-directed learning’, which our respondents too often found synonymous with ‘lack of support’, should be applied with very great caution to medical students' learning in clinical workplaces. [ABSTRACT FROM AUTHOR]

Aim To examine how students' evaluations of the environment, process and outcome of clinical learning interrelated and correlated with assessment results. Method A post hoc study in the 3rd of 5 years in a student-centred, horizontally integrated, objective-based medical curriculum. In the last week of each module, students evaluated what they had learned and how they had learned it using a previously validated, web-based scale. The interrelationships between scale variables and their relationships with summative assessment results were tested using factor analysis, correlation analysis and stepwise multiple regression analysis. Results Student evaluation yielded 4 summary measures: 2 reflected learning outcomes (‘real patient learning’ and ‘curriculum coverage’), 1 reflected process (‘quality of instruction’) and 1 reflected environment (‘conditions for learning’). They fitted a causal model according to which instruction, conditions for learning and curriculum coverage favoured real patient learning. Real patient learning was rated higher in women than men, and the measures were associated more strongly in women. Performance in end-of-year summative assessments was predicted strongly by mid-year performance but by no other measure. Conclusions Students' evaluations of their learning environment and instructional processes correlated with their assessments of 2 outcomes of the curriculum in action: curriculum coverage and real patient learning. There was little shared variance between those measures and students' performance in summative assessments. Given its formative potential, students' evaluation of their curriculum in action could play a useful part in learner-centred clinical education. There is a possibility, which needs further research, that women's evaluations have greater predictive validity than men's. Assessment performance should be regarded not as a solitary gold standard but as just 1 measure of educational outcome. [ABSTRACT FROM AUTHOR]

Presents a systematic review of available evidence to determine how early practical experience in clinical and community settings affects medical education. Data sources from the decade 1992-2001; Benefits from early experience including the development of appropriate attitudes in medical students toward their studies and future practice, as well as directing curriculum toward societal needs. INSET: Best Evidence Medical Education (BEME) coding scheme for....

To characterise the opening of secondary care consultations.We audio-taped 17 first consultations in medical clinics, transcribed them verbatim, and analysed verbal interactions from when the doctor called the patient into the consulting room to when she or he asked clarifying questions.The interviews did not open with the sequence, reported by previous researchers, of‘doctor's soliciting question, patient's opening statement, interruption by the doctor'. Doctors (1) called the patient to the consultation; (2) greeted them; (3) introduced themselves; (4) made a transition to clinical talk; and (5) framed the consultation. They used a referral letter, the case notes, computer records and their prior knowledge of the patient to help frame the consultation, and did so informally and with humour.These 5 steps could help trainees create a context for active listening that is less prone to interruption. [ABSTRACT FROM AUTHOR]

This study aimed to establish whether and under what conditions medical students can learn in a self-directed manner in the clinical environment.A web-based learning management system brought 66 placement students, in a problem-based learning (PBL) medical curriculum, into closer touch with their clinical learning objectives and ways of achieving them. Free response comments from 16 of them during the 7 weeks they used it, transcripts of group discussions before and after the period of use, and responses from all 66 students to a questionnaire were analysed qualitatively.Students were rarely fully autonomous or subservient. They valued affective and pedagogic support, and relied on teachers to manage their learning environment. With support, they were motivated and able to choose how and when to meet their learning needs. The new system was a useful adjunct.Self-direction, interpreted literally, was a method of learning that students defaulted to when support and guidance were lacking. They found‘supported participation’ more valuable. Learning in the clinical environment was a social process with as many differences from, as similarities to, PBL. [ABSTRACT FROM AUTHOR]

To explore how clinicians perceive their roles in problem-based medical education, and how closely those perceptions link to the curriculum they teach.All 14 general physicians in a teaching hospital took part in 6 semistructured discussions, which were analysed phenomenologically.Third year clinical teaching was described in terms that bore little relation to problem-based learning (PBL). Teachers placed great importance on the social dimension of professional learning. They expressed strongly positive affects towards learners and their learning that they found hard to express as PBL tutors. Their narratives of education were remarkably divorced from modern day clinical practice.Problem-based method lacked some important conditions for professional teaching and learning. Traditional apprenticeship is unsustainable under present day conditions of practice. There is a need for new educational methods that help the learner to build a professional identity through social interaction with practitioners. [ABSTRACT FROM AUTHOR]

Aim To help students in a self-directed, problem-based learning (PBL) curriculum learn from a breadth of hospital experience. Methods Clinical units were asked to identify what clinical activities they could make available to interested students on a ‘first-come, first-served’ basis. A centralised, electronic system was developed that allowed students to book a fair, but not excessive, share of those learning opportunities. This web-based programme evolved into a comprehensive timetabling system that managed activities for whole classes of students as well as ‘sign-ups’ booked by individuals. Results The sign-up system offered 1792 hours/week, or 6 hours/student/week, to the hospital's 291 students of learning opportunities additional to firm-based teaching and learning. There were sign-ups in all major specialties and they included rounds, clinics, theatre/investigation sessions and conferences. Students accessed the system as commonly from outside the hospital as within it, and used it to view their timetables as well as to book learning opportunities. The system was used particularly heavily when examinations were imminent, indicating that students found it supportive to their learning. Conclusions We have developed an innovative way of providing experience that is relevant to problem-based, integrative clinical education. Students, as judged by their heavy use of it, value the system. [ABSTRACT FROM AUTHOR]

The authors present their response to a comment made by S. M. Hejri and M. Jalili to their article on outcome competency-based education. The authors support the views of Hejri and Jalili on the failure of a universal curriculum design to approximate differences in culture and the need for local participation in curriculum development. Contrary to Hejri and Jalili, the authors clarified the role of outcome-based education and competency frameworks in providing a basis for assessment.

Objective: Summarise empirical research into patients' experiences of caring in order to promote this as a core condition for the work of health professionals.Methods: A review team: carried out a scoping review with a phenomenological orientation that did not privilege any profession or context of care; comprehensively searched six databases from inception to the present, including all English language articles that report patients' lived experiences of caring; and identified and contrasted uncaring experiences.Results: 43 articles straddled nursing, medicine, and physiotherapy, and a wide range of care settings. Patients experienced caring when competent professionals displayed positive attitudes, communicated effectively, formed relationships, helped them navigate clinical services, and engaged emotionally.Conclusion: This research provides a rich description of caring, which was derived from patients', rather than professionals', experiences.Practice Implications: Whilst publications and basic professional curricula are dominated by the perspectives of single professions, this research describes patients' experiences that can prepare all health professionals to be caring in collaborative, interprofessional practice. [ABSTRACT FROM AUTHOR]

Medical Education 2012: 46: 1074-1087 CONTEXT During early clinical exposure, medical students have many emotive experiences. Through participation in social practice, they learn to give personal meaning to their emotional states. This meaningful social act of participation may lead to a sense of belonging and identity construction. OBJECTIVES The aim of this study was to broaden and deepen our understanding of the interplay between those experiences and students' identity development. Our research questions asked how medical students give meaning to early clinical experiences and how that affects their professional identity development. METHODS Our method was phenomenology. Within that framework we used a narrative interviewing technique. Interviews with 17 medical students on Year 1 attachments to nurses in hospitals and nursing homes were analysed by listening to audio-recordings and reading transcripts. Nine transcripts, which best exemplified the students' range of experiences, were purposively sampled for deeper analysis. Two researchers carried out a systematic analysis using qualitative research software. Finally, cases representing four paradigms were chosen to exemplify the study findings. RESULTS Students experienced their relationships with the people they met during early clinical experiences in very different ways, particularly in terms of feeling and displaying emotions, adjusting, role finding and participation. The interplay among emotions, meaning and identity was complex and four different 'paradigms' of lived experience were apparent: feeling insecure; complying; developing, and participating. CONCLUSIONS We found large differences in the way students related to other people and gave meaning to their first experiences as doctors-to-be. They differed in their ability to engage in ward practices, the way they experienced their roles as medical students and future doctors, and how they experienced and expressed their emotions. Medical educators should help students to be sensitive to their emotions, offer space to explore different meanings, and be ready to suggest alternative interpretations that foster the development of desired professional identities. [ABSTRACT FROM AUTHOR]