Collaborative group reasoning in ward rounds: A critical realist case study

The thesis explored the group reasoning occurring between practitioners during hospital ward rounds. A model of the reasoning was constructed, focused on information gathering, sense-making and decision making. The model explained the role of group reasoning and generated suggestions for evaluating ward rounds, improving medical education and redesigning rounds

Exploring the Validity of Script Concordance Testing to Assess the Clinical Reasoning of Medical Students

Assessment of clinical reasoning is often challenging, as it is a complex process of thinking and decision making. Script Concordance Testing (SCT), using authentic clinical scenarios with diagnostic or management uncertainties, has been developed to assess clinical reasoning. As SCT is a relatively new assessment modality, more empirical evidence is needed to support the validity of SCT scores. This thesis examines key aspects of the validity of SCT scores in the assessment of the clinical reasoning ability of medical undergraduates. A review of the current literature informs the use, design and standard setting of SCT, as well as evidence for its reliability and validity. Exploration of the response patterns of 5 cohorts of graduate-entry medical students in an Australian Medical School showed deliberate avoidance of extreme responses by the lowest quartile students. A post-hoc simulation study, testing the hypothesis that test-wise candidates’ SCT scores were inflated through deliberate avoidance of extreme response-options and selection of neutral response-options, generated an approach to optimising and balancing SCT items for improved SCT score validity. In response to the paucity of empirical studies on the construct validity for SCT scores, the next study showed evidence of progression in SCT scores from medical students, to junior registrars, to experienced general practitioners. Finally, an investigation of candidates’ response process, using a ‘think-aloud’ approach, supported the response process validity of SCT scores. In conclusion, this thesis has demonstrated that: 1) thoughtful design and balance of SCT items can mitigate some of the validity threats to medical student SCT scores; 2) the tendency of SCT scores to progress with increasing levels of clinical practice experience further supports the construct validity of SCT scores; and 3) use of the ‘think-aloud’ approach to explore students’ response process may enhance the utility and educational benefits of SCT. The research supports the validity of SCT in assessing clinical reasoning in undergraduate medical education, and presents practical approaches to enhance the design of the assessment instrument

The effect of structured reflection on the diagnostic accuracy of postgraduate trainees during real patient encounters

Structured reflection has been shown to improve the diagnostic competence of undergraduate and postgraduate trainees in a range of experimental settings using written case scenarios. Evidence supporting the use of this strategy during real patient encounters is lacking. This paper reports on a study conducted to determine the effects of structured reflection on the diagnostic accuracy of postgraduate medical trainees during bedside tutorials using real patient encounters. Method Fifty-five postgraduate trainees in Internal Medicine at the University of Cape Town, South Africa, were prospectively studied during 18 beside tutorials using real patient encounters. Each patient encounter was conducted as a 4-stage diagnostic process and a diagnostic accuracy score (DAS) was calculated for all participants at each stage: • DAS 1: immediately upon arrival at the patient's bedside (visual cues only); • DAS 2: after an oral presentation of the interview and physical examination findings (pre-reflection); • DAS 3: after review of the clinical data using a process of structured reflection (post-reflection); • DAS 4: after discussion of the patient facilitated by the attending physician (facilitated reflection). Memory structure and flexibility in thinking of participants were evaluated using the Diagnostic Thinking Inventory (DTI) and compared to their post-reflection diagnostic accuracy scores. Results A total of 212 diagnostic events were studied. Friedman's test demonstrated a significant difference when comparing the median diagnostic accuracy scores (DAS) of the respective stages of the diagnostic process (χ² (3) = 406.34, p value < 0.001). The Wilcoxon signed-rank test confirmed that there was a significant difference between the immediate DAS (DAS 1) and the pre-reflection DAS (DAS 2) (Z = 8.66, p value < 0.001), the pre-reflection DAS (DAS 2) and the post reflection DAS (DAS 3) (Z = 4.98, p value < 0.001). Linear regression identified a significant relationship between DTI scores and DAS 3 (p value = 0.035), however this explains only a small portion of the variation in the data (r² = 0.093). Conclusion Structured reflection improved the diagnostic accuracy of postgraduate trainees during real patient encounters at the bedside. These data provide support for the suggestion that clinical teachers should consider adding structured reflection to their toolbox of bedside teaching strategies. In addition, DTI scores may help clinical teachers identify trainees struggling with the development of diagnostic expertise

Exploration, design and application of simulation based technology in interventional cardiology

Medical education is undergoing a vast change from the traditional apprenticeship model to technology driven delivery of training to meet the demands of the new generation of doctors. With the reduction in the training hours of junior doctors, technology driven education can compensate for the time deficit in training. Each new technology arrives on a wave of great expectations; sometimes our expectations of true change are met and sometimes the new technology remains as a passing fashion only. The aim of the thesis is to explore, design and apply simulation based applications in interventional cardiology for educating the doctors and the public. Chapters 1and 2 present an overview of the current practice of education delivery and the evidence concerning simulation based education in interventional cardiology. Introduction of any new technology into an established system is often met with resistance. Hence Chapters 3 and 4 explore the attitudes and perceptions of consultants and trainees in cardiology towards the integration of a simulation based education into the cardiology curriculum. Chapters 5 and 6 present the “i-health project,” introduction of an electronic form for clinical information transfer from the ambulance crew to the hospital, enactment of case scenarios of myocardial infarction of varied levels of difficulty in a simulated environment and preliminary evaluation of the simulation. Chapter 7 focuses on educating the public in cardiovascular diseases and in coronary interventional procedures through simulation technology. Finally, Chapter 8 presents an overview of my findings, limitations and the future research that needs to be conducted which will enable the successful adoption of simulation based education into the cardiology curriculum.Open Acces

Using video reflexive ethnography to explore the use of variable rate intravenous insulin infusions

Background: The use of variable rate intravenous insulin infusion (VRIII) is a complex process that has consistently been implicated in reports of error and consequent harm. Investment in patient safety has focused mainly on learning from errors, though this has yet to be proved to reduce error rates. The Resilient Health Care approach advocates learning from everyday practices. Video reflexive ethnography (VRE) is an innovative methodology used to capture, reflect on and thereby improve these. This study set out to explore the use of VRIIIs by utilising the VRE methodology. Methods: This study was conducted in a Vascular Surgery Unit. VRE methodology was used to collect qualitative data that involved videoing healthcare practitioners caring for patients treated with VRIII and discussing the resulting clips with participants in reflexive meetings. Transcripts of these were subjected to thematic analysis. Quantitative data (e.g. blood glucose measurements) were collected from electronic patient records in order to contextualise the outcomes of the video-observed tasks. Results: The use of VRE in conjunction with quantitative data revealed that context-dependent adaptations (seeking verbal orders to treat hypoglycaemia) and standardised practices (using VRIII guidelines) were strategies used in everyday work. Reflexive meetings highlighted the challenges faced while using VRIII, which were mainly related to lack of clinical knowledge, e.g. prescribing/continuing long-acting insulin analogues alongside the VRIII, and problems with organisational infrastructure, i.e. the wireless blood glucose meter results sometimes not updating on the electronic system. Reflexive meetings also enabled participants to share the meanings of the reality surrounding them and encouraged them to suggest solutions tailored to their work, for example face-to-face, VRIII-focused training. Conclusions: VRE deepened understanding of VRIII by shedding light on its essential tasks and the challenges and adaptations entailed by its use. Future research might focus on collecting data across various units and hospitals to develop a full picture of the use of VRIIIs

Patient deterioration : the effect of humans and systems in one health care system

The failure to recognise and to respond to adult deteriorating patients in general hospital wards leads to unexpected and potentially preventable deaths. Aims. 1. To improve the understanding of the clinical processes and influences involved in managing patient deterioration. 2. To examine the effect of a deteriorating patient intervention on clinical processes and patient outcome. 3. To determine if the effects of a deteriorating patient intervention are sustainable. Methods. Quantitative Studies. i. Observational Study: Clinical processes in 34 patients undergoing 45 Medical Emergency Team reviews were examined retrospectively. ii. lnterventional Study: A prospective controlled trial, before and after a multifaceted intervention for managing patient deterioration was undertaken in two wards in two hospitals for two{u00AD} four month periods. Changes in deteriorating patient clinical processes and outcome were measured. iii. Sustainability Study: Adult patients admitted to two wards in one hospital during three four{u00AD} month periods, one before, one immediately after the patient deterioration intervention and one two years later. Changes in deteriorating patient clinical processes and outcome were measured. Qualitative Studies. i. Behavioural Study: Interviews of 12 healthcare workers involved in the patient deterioration intervention were undertaken to generate a model of why behaviour changed with the installation of the multifaceted intervention for managing patient deterioration. Grounded theory methodology described on page 80 was used. ii. Human Element Study: Focus groups of healthcare workers were held to generate discussion and used to generate a model of the influences on healthcare professionals in managing patient deterioration. Grounded theory methodology was used. Results. Clinical processes for managing patient deterioration were found to be deficient. Deficiencies included infrequent documentation of vital signs, particularly respiratory rate and limited involvement of senior decision makers leaving junior clinicians to manage patient deterioration, which delayed appropriate treatment. The multifaceted intervention significantly improved patient outcome and improved behaviour such as documentation of vital signs, supported by a hospital policy, and timeliness of medical review, triggered by more confident nursing staff underpinned by objective evidence (the modified early warning score) of patient deterioration. Improvement in timeliness of medical review and documentation of vital signs were sustained two years later but patient hospital outcome and the nurses calling for further medical help were not. Further investigation of behaviours that were not sustained revealed that junior medical and nursing staff lacked adequate clinical experience to facilitate timely decision making necessitating input from their consultants. Timely and appropriate communication was hindered through fear, lack of confidence or lack of knowledge and poor consultant approachability. Conclusion. Identified shortcomings in the teamwork managing patient deterioration improved with the installation of a multifaceted intervention and, improved patient hospital outcome. Significant behavioural issues, especially communication with consultants, were identified as likely to hamper further improvement. In an age of shift work and reduced clinical experience, enhanced decision making will need a more intelligent system that can accurately detect patients at risk of patient deterioration and improved access to consultants to gain maximal benefit from the healthcare team

Exploring the development of clinical reasoning skills among doctors-in-training

Clinical reasoning is complex, difficult to conceptualise and learn, and important as it is closely linked with medical expertise. Learning clinical reasoning skills is primarily an unguided and subconscious process for doctors-in-training, and there is a need for an evidence based, explicit approach to support the learning of these core skills. The focus of this research is the process by which doctors-in-training learn clinical reasoning skills within the context of General Medicine in north Queensland. The literature to date has been extensive but has struggled to identify a practical framework for doctors-in-training which clearly supports their learning of clinical reasoning skills. This program of research investigated four factors identified in the literature as influencing the development of clinical reasoning skills: the metacognitive awareness levels of doctors-in-training; the learning climate of Intern doctors in their first year of clinical work; the influence of Consultants; and the role of Interns as learners. The first factor was investigated by exploring whether metacognitive awareness correlated with performance in medical undergraduate examinations, and whether there was an increase in metacognitive awareness from the first to the fifth-year of the undergraduate medical course. Volunteer medical students completed the Metacognitive Awareness Inventory (MAI), as well as consenting to give access to their examination scores for this study. For the first-year undergraduate doctors-in-training there were correlations between the Knowledge of Cognition domain of the MAI and their end of year examination results, but not with the Regulation of Cognition domain. For fifth-year students there were correlations between both the Knowledge and Regulation of Cognition domains and their end of year examination results. This study found that the overall MAI scores were not significantly different between first and fifth-year undergraduates in this sample. The Regulation of Cognition domain and its sub-domains, regarded as key factors in clinical reasoning skill development, did not significantly differ between first and fifth-year undergraduate doctors-in-training. The second factor investigated was whether the learning climate of Intern doctors-in-training was conducive to learning. The validated Dutch Resident Educational Climate Test (D-RECT) was used, and written responses invited to the question 'What three aspects of the junior doctor learning environment would you alter?' The Coaching and Assessment and the Relations between Consultants domains were identified as significantly lower in General Medicine than for other units, triangulating the written comments provided by the Interns. The third factor investigated Consultant Physicians as role models for doctors-in-training learning clinical reasoning skills. The focus of the semi-structured interviews explored how the Physicians understood clinical reasoning, their understanding of how they had acquired these skills, and the ways they sought to foster these skills among their doctors-in-training. The seven Consultants described their journey to gaining clinical reasoning expertise as being unguided, generally subconscious and seldom discussed. Most Consultants spoke of being unaware of their own journey to gaining clinical reasoning expertise, and did not regard themselves as role models for doctors-in-training. Most Consultants indicated that acquiring clinical knowledge and learning to think about their decision-making processes (metacognition), were crucial for acquiring expertise, but very few Consultants explained how they could intentionally foster these skills. The final factor was explored by investigating how Intern doctors-in-training understood their own development of clinical reasoning skills. At the start of their General Medicine term, Interns were presented with basic information about clinical reasoning. At the end of that term, participating Interns were interviewed. A paper copy of the presentation given at the start of the term was used to stimulate Intern reflections on their learning during the General Medicine term. The 27 Interns interviewed identified that learning clinical reasoning was a tacit, personal journey influenced by enabling and inhibitory factors. The Interns attributed the differences between their clinical reasoning skills and those of their Consultants as being primarily due to the experience and superior clinical knowledge of the Consultants. A multi-methods research design was used to answer the research questions across the four studies. The first two factors were investigated using quantitative methods, while qualitative methods were employed for the last two. The multi-methods approach enabled findings from the separate studies to be triangulated, supporting confidence in the trustworthiness of the synthesised outcomes and reducing an over-dependence on any individual study. The Synthesis and Proposed Framework chapter initially integrates the findings from the four studies to provide an overall understanding of how clinical reasoning skills are currently fostered in north Queensland. These synthesised results are then used to propose an evidence-based learning model and a method for its implementation at the teaching hospital. The modified Cognitive Apprenticeship Learning Model (mCALM) could help to make expert thinking visible by explicitly supporting constructivist learning practices, metacognitive skills, deliberate practice and a conducive learning climate. The mCALM appears well suited to explicitly fostering the learning of clinical reasoning skills for doctors-in-training in north Queensland

Instilling reflective practice – The use of an online portfolio in innovative optometric education Accepted as: e‐poster Paper no. 098

At UCLAN we are breaking the mould and have developed a blended learning MSci optometry programme which is the first blended learning course in optometric education in the UK and the first to use a practice-based online portfolio. Optometry has traditionally been taught as a 3‐year undergraduate programme. Upon successful graduation, students are required to complete a year in practice and meet the General Optical Council's (GOC) “ability to” core competencies. However, a recent study by the GOC found that 76% of students felt unprepared for professional practice with insufficient clinical experience and in response, the GOC is currently undertaking an educational strategic review. To ensure the students receive high-quality clinical experience in the workplace, we have developed an online logbook and portfolio. Students log their experiences, learning points and reflections. The portfolio is closely monitored both by the student's mentor in practice and by academic staff. The content and reflections logged by the students then helps to drive the face to face teaching, small group discussions and clinical experiences provided by the university