Preparedness is not enough: understanding transitions as critically intensive learning periods

Abstract

Abstract:Objectives: Doctors make many transitions whilst they are training and throughout their ensuing careers. Despite studies showing that transitions in other high risk professions such as aviation have been linked to increased risk in the form of adverse outcomes, the effects of changes on doctors' performance and consequent implications for patient safety have been under-researched. The purpose of this project was to investigate the effects of transitions upon medical performance. Methods:The project sought to focus on the inter-relationships between doctors and the complex work settings into which they were transitioning. To this end, a 'collective' case study of doctors was designed. Key transitions for Foundation Year and Specialist Trainee doctors were studied. Four levels of the case were examined: the regulatory and policy context; employer requirements; the clinical teams in which doctors worked; and the doctors themselves. Data collection included interviews, observations and desk-based research.. Results:We identified a number of problems with doctors' transitions that can all adversely affect performance. A) Transitions are regulated but not systematically monitored. B) Actual practice (as observed and reported) was determined much more by situational and contextual factors than by the formal (regulatory and management) frameworks. C) Trainees' and health professionals' accounts of their actual experience of work showed how performance is dependent on local learning environment. D) We found that the increased regulation of clinical activity through protocols and care pathways helps trainees' performance whilst the less regulated aspects of work such as rotas, induction and multiple transitions within rotations can impede the transition. Conclusions:Transitions may be reframed as critically intensive learning periods (CILPs) in which doctors engage with the particularities of the setting and establish working relationships with doctors and other professionals. Institutions and wards have their own learning cultures which may or may not recognise that transitions are CILPS. The extent to which these cultures take account of transitions as CILPs will contribute to the performance of new doctors. There are therefore implications for practice, and for policy, regulation and research.

Assessment of prescription writing skills among undergraduate medical students

“…There is some evidence suggesting improvement in training. 18 Many studies opine that once the newly qualified doctors exposed to workplace prescription writing, they retrospectively feel that there was insufficient emphasis on practical aspects of writing prescription in undergraduate curriculum. 15,19 Interns share this view as well.…”

Effectiveness of a rural longitudinal integrated clerkship in preparing medical students for internship

“…Mindfulness training can help alleviate stress by providing coping mechanisms (Barbosa et al, 2013;Bullock et al, 2013). Practice competence is a function both of the individual doctor's training and the organisational culture in which that doctor operates (Kilminster, Zukas, Quinton, & Roberts, 2011), and so no training program can expect to fully prepare a doctor to function well right from the start in a new setting at an advanced stage of knowledge.…”

Developing understandings of clinical placement learning in three professions: Work that is critical to care

“…Our approach to analysis developed the iterative process described in our previous research on transitions (Kilminster et al, 2011) and was informed by the practice-based understandings introduced at the beginning of this paper.…”

“…However, our work (Kilminster et al, 2010(Kilminster et al, , 2011Zukas and Kilminster 2012) suggests that this emphasis on preparedness is misplaced because it fails to recognise the distributed, collaborative nature of actual practice.…”

“…Our previous study of doctors' transitions showed how doctors' practice was highly dependent on "the setting, the trust in question, time of day or night, the composition of the team and whether other members of the team were present" (Kilminster et al, 2011(Kilminster et al, , p. 1011. Rather than suggesting that doctors can and should be better prepared, we recommended that transition points be recognised as critically intensive learning periods (CILPs).…”