INTRODUCTION: Impaired wellness among junior doctors is a significant problem. Connectedness and sense of belonging may be important factors to prevent and reduce mental ill-health. Shared social spaces in which health care staff can meet informally are thought to improve connectedness; however, these spaces are in decline. It is unclear what is known about such spaces, how they are used, and their impact on wellness and learning. This study aims to identify and synthetise available literature that informs our current understanding of the nature of shared social spaces as an intervention impacting wellness and learning of junior doctors. METHODS: a scoping review was conducted following the Arksey and O'Malley five-step framework. The review question is 'What is the evidence of the impact of shared social spaces on wellness and learning of junior doctors?' We searched five databases: MEDLINE, EMBASE, APA PsychINFO, APA PsychExtra, and ERIC. We conducted thorough supplementary searches in addition to the database search. RESULTS: We included 41 articles. These were predominantly letters, commentaries, and editorials with only five primary research studies. We identified four significant common attributes of shared social spaces, which can be credited with positive impacts on wellness and learning: (1) Informal: fostering connectedness and belonging, trust and teamwork and offering access to informal help and support; (2) safe: allowing reflection, debrief and raising of concerns; (3) functional: there is planning of clinical care activity, sense of control and engagement from users and provision of refreshment; (4) legitimate: regular maintenance and use of shared social spaces affect role modelling, sustainability and wellness culture. DISCUSSION: This review identified several ways in which shared social spaces impact positively on learning and wellness. There is little primary research in this area. Future research would be useful to further examine how and why this works.

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might 'tip the balance' towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

AbstractBackgroundHigh rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics.Sources of dataKey demographic, service architecture (structural features of work) and well-being indicators were identified and reviewed by a stakeholder group. Data searching prioritized NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence.FindingsKey differences between professions were: (i) demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) well-being: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double.Growing pointsSociocultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve well-being.Areas timely for developing researchMulti-level systems approaches to well-being are required that consider intersectionality and structural differences between professions; together with inter-professional national databases to facilitate monitoring.

BACKGROUND: Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care-drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives-and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts. METHODS: Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches-resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries. RESULTS: One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective. CONCLUSIONS: Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this. STUDY REGISTRATION: PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup/.

CONTEXT: the prevalence of stress, burnout and mental health disorders in medical students and doctors is high. It has been proposed that there may be an association between levels of tolerance of ambiguity (ie an ability to tolerate a lack of reliable, credible or adequate information) in clinical work and psychological well-being within this population. The aims of this systematic review were: (i) to assess the nature and extent of the literature available, in order to determine if there is an association, and (ii) to develop a conceptual model proposing possible mechanisms to underpin any association, in order to inform subsequent research. METHODS: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched for articles published from inception to September 2018. Additional literature was identified by searching the reference lists of included articles, forward searches of included articles, hand searches of key journals and a grey literature search. of the 671 studies identified, 11 met the inclusion criteria. A qualitative synthesis of included studies was performed. RESULTS: all 11 included studies reported an association between a lower level of tolerance of ambiguity or uncertainty and reduced psychological well-being. Included studies were heterogeneous in terms of population and measurement approach, and were often of low methodological quality. Subsets of items from previously developed scales were often used without sufficient consideration of the impact of new combinations of items on scale validity. Similar scales were also scored inconsistently between studies, making comparison difficult. CONCLUSIONS: There appears to be an association between tolerance of ambiguity and psychological well-being. This provides new opportunities to understand and prevent the development of stress, burnout and mental health disorders in medical students and doctors. The conceptual model developed provides a framework for future research, which we hope will prevent wasted research effort through duplication and promote higher methodological quality.

Context: Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. Methods: We undertook a scoping literature review, using search terms such as ‘feedback’ and ‘effectiveness’ in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. Results: a total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. Conclusions: We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.

Introduction: Given the importance of their roles in society, the education of professionals is a central concern for providers and recipients of public services. In this article we consider the contribution of research on professional learning to current debate on the form and content of professional education. This mapping review asked, “What does the research literature tell us about the characteristics of research into Professional Learning across professions?”
Methods:. We identified and synthesised primary research involving post-qualification professionals’ professional learning. We searched seven databases using terms such as “professional learning”, “professional development” and “continuing education” from 2000 to date. We carefully screened articles against agreed criteria, extracted data and mapped the findings.
Results:. After removing duplicates, 20,616 records remained. After full text screening, 356 articles were included: 266 from Teaching (75%), 77 from Healthcare (22%) and 13 from another profession or cross-professional (4%). Three included papers spanned professions. Only 6% articles studied the institution as the unit of analysis (rather than the individual). Around half of the included papers (49%) included an intervention. Most Teaching interventions were proximal to the workplace whereas most Healthcare/Other studies were distal to the workplace, perhaps reflecting stage of development of the research field.
Discussion:. Our study synthesised a heterogeneous literature to indicate the types or research that are needed to progress the debate. The clear differences in ‘style’ between professions suggested that collaboration could provide mutual benefit. Future research requires studies that report research in ways that lend themselves to evidence synthesis or replication.

Introduction: Given the importance of their roles in society, the education of professionals is a central concern for providers and recipients of public services. In this article we consider the contribution of research on professional learning to current debate on the form and content of professional education. This mapping review asked, “What does the research literature tell us about the characteristics of research into Professional Learning across professions?”

Methods:. We identified and synthesised primary research involving post-qualification professionals’ professional learning. We searched seven databases using terms such as “professional learning”, “professional development” and “continuing education” from 2000 to date. We carefully screened articles against agreed criteria, extracted data and mapped the findings.

Results:. After removing duplicates, 20,616 records remained. After full text screening, 356 articles were included: 266 from Teaching (75%), 77 from Healthcare (22%) and 13 from another profession or cross-professional (4%). Three included papers spanned professions. Only 6% articles studied the institution as the unit of analysis (rather than the individual). Around half of the included papers (49%) included an intervention. Most Teaching interventions were proximal to the workplace whereas most Healthcare/Other studies were distal to the workplace, perhaps reflecting stage of development of the research field.

Discussion:. Our study synthesised a heterogeneous literature to indicate the types or research that are needed to progress the debate. The clear differences in ‘style’ between professions suggested that collaboration could provide mutual benefit. Future research requires studies that report research in ways that lend themselves to evidence synthesis or replication.

BACKGROUND: a positive doctor-patient relationship is a crucial part of high-quality patient care. There is a general perception that it has been changing in recent years; however, there is a lack of evidence for this. Adapting to the changing doctor-patient relationship has been identified as an important skill doctors of the future must possess. This study explores (1) multiple stakeholder perspectives on how the doctor-patient relationship is changing and (2) in what ways medical graduates are prepared for working in this changing doctor-patient relationship. METHODS: We conducted a national qualitative study involving semi-structured interviews with multiple stakeholders across the United Kingdom. Interviews lasting 45-60 minutes were conducted with 67 stakeholders including doctors in the first 2 years of practice (ECD's), patient representatives, supervisors, deans, medical educators and other health care professionals. The interviews were audiorecorded, transcribed, analysed, coded in NVivo and analysed thematically using a Thematic Framework Analysis approach. RESULTS: the main ways the doctor-patient relationship was perceived to be changing related to increased shared decision making and patients having increasing access to information. Communication, patient-centred care and fostering empowerment, were the skills identified as being crucial for preparedness to work in the changing doctor-patient relationship. Graduates were reported to be typically well-prepared for the preconditions (communication and delivering patient-centred care) of patient empowerment, but that more work is needed to achieve true patient empowerment. CONCLUSION: This study offers a conceptual advance by identifying how the doctor-patient relationship is changing particularly around the 'patient-as-knowledge-source' dimension. On the whole ECD's are well-prepared for working in the changing doctor-patient relationship with the exception of patient empowerment skills. Further research is now needed to provide an in-depth understanding of patient empowerment that is shared among key stakeholders (particularly the patient perspective) and to underpin the design of educational interventions appropriate to career stage.

INTRODUCTION: Impaired wellness among junior doctors is a significant problem. Connectedness and sense of belonging may be important factors to prevent and reduce mental ill-health. Shared social spaces in which health care staff can meet informally are thought to improve connectedness; however, these spaces are in decline. It is unclear what is known about such spaces, how they are used, and their impact on wellness and learning. This study aims to identify and synthetise available literature that informs our current understanding of the nature of shared social spaces as an intervention impacting wellness and learning of junior doctors. METHODS: a scoping review was conducted following the Arksey and O'Malley five-step framework. The review question is 'What is the evidence of the impact of shared social spaces on wellness and learning of junior doctors?' We searched five databases: MEDLINE, EMBASE, APA PsychINFO, APA PsychExtra, and ERIC. We conducted thorough supplementary searches in addition to the database search. RESULTS: We included 41 articles. These were predominantly letters, commentaries, and editorials with only five primary research studies. We identified four significant common attributes of shared social spaces, which can be credited with positive impacts on wellness and learning: (1) Informal: fostering connectedness and belonging, trust and teamwork and offering access to informal help and support; (2) safe: allowing reflection, debrief and raising of concerns; (3) functional: there is planning of clinical care activity, sense of control and engagement from users and provision of refreshment; (4) legitimate: regular maintenance and use of shared social spaces affect role modelling, sustainability and wellness culture. DISCUSSION: This review identified several ways in which shared social spaces impact positively on learning and wellness. There is little primary research in this area. Future research would be useful to further examine how and why this works.

Students from lower socio-economic backgrounds who were educated in state funded schools are underrepresented in medicine in the UK. Widening access to medical students from these backgrounds has become a key political and research priority. It is known that medical schools vary in the number of applicants attracted and accepted from non-traditional backgrounds but the reasons for this are poorly understood. This study aims to explore what applicants value when choosing medical schools to apply to and how this relates to their socioeconomic background. We conducted a multicentre qualitative interview study, purposively sampling applicants and recent entrants based on socioeconomic background, stage of application and medical school of application. We recruited participants from eight UK medical schools. Participants attended semi-structured interviews. We performed a framework analysis, identifying codes inductively from the data. Sixty-six individuals participated: 35 applicants and 31 first year medical students. Seven main themes were identified; course style, proximity to home, prestige, medical school culture, geographical area, university resources, and fitting in. These were prioritised differently depending on participants' background. Participants from lower socioeconomic backgrounds described proximity to home as a higher priority. This was typically as they intended to be living at home for at least part of the course. Those from higher socioeconomic backgrounds were more concerned with the perceived prestige of medical schools. Since medicine is a highly selective course, only offered at a minority of UK higher education institutions, these differences in priorities may help explain observed differential patterns of medical school applications and success rates by applicant social background.

Background
The STITCH trial published high quality randomised data demonstrating the superiority of small bite over mass closure for the reduction of incisional hernias following elective laparotomy. Previous research has shown time taken for the implementation of evidenced based practise is, on average, 17 years. We aim to understand barriers to implementation of small bite closure into clinical practise.
Methods
Semi-structured interviews were completed with surgeons at a single institution in South West England. Interview transcripts underwent thematic analysis with themes identified following coding and subsequent iterative discussions within the research team.
Results
Nine interviews of eight general surgical consultants and registrars and one urological consultant were performed. Average duration of the interviews was 22:49 minutes (14:20-36.37). Three themes were identified as barriers to the introduction of small bite closure. ‘Trusting the Evidence & Critical Appraisal’ highlighted issues with the published trial and access to data. ‘Surgical Attitude to Risk’ identified differences in personality traits and the importance of guidelines from professional bodies to support practise change. ‘Adopting Evidence in Practise’ discussed training availability, system and patient issues within local hospitals.
Conclusion
Surgeons have to manage the balance between pushing boundaries to improve outcomes and a safety first approach. This influences the adoption of new techniques, such as small bite closure. This study has identified three themes that result in differences in the adoption of a new technique for midline closure. There are possible areas for intervention, to decrease the adoption time for randomised evidence.

Surgical specialties account for a high proportion of antimicrobial use in hospitals, and misuse has been widely reported resulting in unnecessary patient harm and antimicrobial resistance. We aimed to synthesize qualitative studies on surgical antimicrobial prescribing behavior, in hospital settings, to explain how and why contextual factors act and interact to influence practice. Stakeholder engagement was integrated throughout to ensure consideration of varying interpretive repertoires and that the findings were clinically meaningful. The meta-ethnography followed the seven phases outlined by Noblit and Hare. Eight databases were systematically searched without date restrictions. Supplementary searches were performed including forwards and backwards citation chasing and contacting first authors of included papers to highlight further work. Following screening, 14 papers were included in the meta-ethnography. Repeated reading of this work enabled identification of 48 concepts and subsequently eight overarching concepts: hierarchy; fear drives action; deprioritized; convention trumps evidence; complex judgments; discontinuity of care; team dynamics; and practice environment. The overarching concepts interacted to varying degrees but there was no consensus among stakeholders regarding an order of importance. Further abstraction of the overarching concepts led to the development of a conceptual model and a line-of-argument synthesis, which posits that social and structural mediators influence individual complex antimicrobial judgements and currently skew practice towards increased and unnecessary antimicrobial use. Crucially, our model provides insights into how we might 'tip the balance' towards more evidence-based antimicrobial use. Currently, healthcare workers deploy antimicrobials across the surgical pathway as a safety net to allay fears, reduce uncertainty and risk, and to mitigate against personal blame. Our synthesis indicates that prescribing is unlikely to change until the social and structural mediators driving practice are addressed. Furthermore, it suggests that research specifically exploring the context for effective and sustainable quality improvement stewardship initiatives in surgery is now urgent.

AbstractBackgroundHigh rates of poor mental health in healthcare staff threatens the quality and sustainability of healthcare delivery. Multi-factorial causes include the nature and structure of work. We conducted a critical review of UK NHS (England) data pertaining to: doctors, nurses, midwives and paramedics.Sources of dataKey demographic, service architecture (structural features of work) and well-being indicators were identified and reviewed by a stakeholder group. Data searching prioritized NHS whole workforce sources (focusing on hospital and community health services staff), which were rated according to strength of evidence.FindingsKey differences between professions were: (i) demographics: gender (nursing and midwifery female-dominated, doctors and paramedics more balanced); age (professions other than doctors had ageing workforces); ethnicity (greater diversity among doctors and nurses); (ii) service architecture: despite net staffing growth, turnover and retention were problematic in all professions; 41.5% doctors were consultants but smaller proportions held high grade/band roles in other professions; salaries were higher for doctors; (iii) well-being: all reported high job stress, particularly midwives and paramedics; sickness absence rates for nurses, midwives and paramedics were three times those of doctors, and presenteeism nearly double.Growing pointsSociocultural factors known to increase risk of poor mental health may explain some of the differences reported between professions. These factors and differences in service architecture are vital considerations when designing strategies to improve well-being.Areas timely for developing researchMulti-level systems approaches to well-being are required that consider intersectionality and structural differences between professions; together with inter-professional national databases to facilitate monitoring.

Medical education research is becoming increasingly concerned with the value (defined as "educational outcomes per dollar spent") of different teaching approaches. However, the financial costs of various approaches to teaching anatomy are under-researched, making evidence-based comparisons of the value of different teaching approaches impossible. Therefore, the aims of this study were to report the cost of six popular anatomy teaching methods through a specific, yet generalizable approach, and to demonstrate a process in which these results can be used in conjunction with existing effectiveness data to undertake an economic evaluation. A cost analysis was conducted to report the direct and indirect costs of six anatomy teaching methods, using an established approach to cost-reporting. The financial information was then combined with previously published information about the effectiveness of these six teaching methods in increasing anatomy knowledge, thereby demonstrating how estimations of value can be made. Dissection was reported as the most expensive teaching approach and computer aided instruction/learning (CAI/L) was the least, based on an estimation of total cost per student per year and assuming a student cohort size of just over 1,000 (the United Kingdom average). The demonstrated approach to economic evaluation suggested computer aided instruction/learning as the approach that provided the most value, in terms of education outcomes per dollar spent. The study concludes by suggesting that future medical education research should incorporate substantially greater consideration of cost, in order to draw important conclusions about value for learners.

Introduction

General practitioners (GPs) play a crucial role in delivering primary care; however, there is a shortage of GPs and a recruitment crisis in many parts of the world. Additionally, GPs often work under high pressure due to increasing societal demand for their services, resulting from the aging population, increasingly complex patient cases, climate change, pandemics, and other factors. Initiatives such as changes in medical technology, new ways of treating patients, and increasing allied healthcare professionals' involvement are attempting to address these challenges. Therefore, the role of GPs is changing, and new approaches to recruitment and training are required. This thesis explores different typologies of education and training pathways for GPs and their characteristics.

Methods

The study consisted of two sequential phases. In phase 1, a scoping review used search terms such as ‘General practice’ or ‘Family medicine’ and ‘medical education or training’ in Ovid Medline, EmBase, and ERIC. It identified studies published in English since 2010, describing education and training pathways for GPs. Three typologies based on GPs’ roles in healthcare systems were developed. In phase 2, semi-structured interviews with 28 stakeholders in the training process for GPs helped to extend understanding of the three typologies. The stakeholders were located in three countries (Vietnam, UK, and the USA) selected as representative of each typology.

 
Results

In phase 1, 90 articles were included in the scoping review, of which 47 discussed both undergraduate and postgraduate programmes. The different roles of GPs within the health care system were reflected in distinct education and training pathways. Three typologies were developed: ‘Gatekeeper’ (where patients cannot access secondary or tertiary services without GP referral), ‘Doctor of Choice’ (where patients can choose to see a GP or specialist and can access secondary or tertiary care directly), and ‘Team member’ (where patients can access a network of health professionals in the community).

In phase 2, three main themes related to the typologies emerged: (i) characteristics of training pathways, (ii) influencing factors, and (iii) stages of the training pathway. Training pathways were diverse and changed over time. Five influencing factors to GP training were: programme design (curriculum, pedagogy, assessment), culturally and historically established structures (e.g. duration and training settings), changing role of GPs, changing expectations of patients and society, and changing health needs. There were three main stages of training pathways: entering the pathway as medical students, continuing the pathway as trainees, and exiting the pathway as GPs. The significant distinctions of the three stages between the typologies were reflected.

 
Discussion

The study offers a provisional typology with typical characteristics and factors influencing GP training. These findings highlight: (1) diversity and complexity in education and training for GPs; (2) a strong connection between training pathways with practice settings and types of primary care provision in countries; (3) that a ‘one size fits all’ approach is not appropriate in designing and developing GP training programmes; (4) that barriers exist to the mobility of GPs between countries. Therefore, the typology provides a reference for medical educators and policymakers. Conceptualising the diversity in education and training pathways can inform the implementation of educational and training transformation for GPs in different countries.

There is a high prevalence of psychological morbidity in doctors-in-training (medical students and trainee doctors) with a subsequent impact on delivery of healthcare. The practice of medicine involves inherent ambiguity leading to uncertainty, and there is growing evidence that reduced tolerance of ambiguity in doctors-in-training may be associated with reduced psychological well-being. However research into this important construct is hampered by a lack of conceptual clarity relating to the underpinning constructs, and a lack of validated measurement tools. Furthermore, it remains unclear if tolerance of ambiguity, in medical students, doctors and similar professional groups, such as vets, is a dynamic state that can be influenced by medical education interventions.
The aim of this thesis is to develop understanding and approaches to measurement of the tolerance of ambiguity construct in doctors-in-training, using veterinary trainees as a comparison group, and to improve understanding of the potential association between tolerance of ambiguity and psychological well-being.
This thesis describes the development of a high quality Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) measurement scale. Variants of the scale were used to compare tolerance of ambiguity in medical and veterinary students. Existing literature was assessed to determine if there is an association between tolerance of ambiguity and psychological well-being in the medical population. A conceptual model is proposed relating to the tolerance of ambiguity construct, and the mediating and moderating factors that may influence the relationship with psychological well-being. The broader ambition of this thesis is to support development and evaluation of future educational interventions which will ultimately improve psychological well-being of doctors-in-training, and support improved workforce sustainability and high quality patient care.

Introduction: Variation in medical education and training amongst countries is well reported but evidence syntheses of similarities and differences are rare. We developed a typology of education and training pathways for General Practitioners (or equivalent) based on a scoping review of international peer-reviewed literature.Methods: Applying search terms such as 'General practice' or 'Family medicine' and 'medical education or training' in Ovid Medline, Embase, and ERIC, identified studies published since 2010 describing education and training pathways for GPs. Inclusion criteria were used to select studies for data extraction and thematic analysis to characterise distinct typologies.Results: 90 articles were included in the scoping review of which 47 discussed both undergraduate and postgraduate programmes and three typologies based on GPs' role in the healthcare system identified:'Gatekeeper': Patients cannot access secondary or tertiary service without GP referral.'Doctor of choice': Patients can choose to see a specialist and access secondary or tertiary care directly.'Team member': Patients can access a network of health professionals in the community.Conclusion: the typology provides a reference for medical educators and policymakers. Conceptualising the diversity in education and training pathways can inform the implementation of educational and training transformation for GPs in different contexts.

As a clinician, you will often combine patients' narratives with test results in order to obtain a coherent picture and then decide on a way forward. As an educator, you are also likely to combine different information from your learners to arrive at the best feedback, judgement or supervision plan. This is what researchers do when undertaking mixed-methods research: qualitative and quantitative data are typically brought together to provide different insights than could be achieved with a single type of data and analysis. Mixed-methods research has much to offer the clinical teacher but may involve more complex study designs than other types of research. Therefore, this article aims to highlight the different designs of mixed-methods research, and the opportunities and challenges that it provides, in order to support researchers who may be undertaking their first mixed-methods research study.

. Background
. The growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem.
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.
. Objectives
. Our aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.
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. Design
. Realist literature review consistent with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.
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. Data sources
. Bibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.
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. Review methods
. We included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations.
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. Results
. A total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost information and none reported a health economic analysis. The 19 context–mechanism–outcome configurations demonstrated that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job, and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote well-being. Interventions creating a people-focused working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors needed to have confidence in an intervention for the intervention to be effective.
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. Limitations
. Variable quality of included literature; limited UK-based studies.
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. Future work
. Use this evidence synthesis to refine, implement and evaluate interventions.
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. Study registration
. This study is registered as PROSPERO CRD42017069870.
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. Funding
. This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 19. See the NIHR Journals Library website for further project information.
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BACKGROUND: Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care-drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives-and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts. METHODS: Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches-resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries. RESULTS: One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective. CONCLUSIONS: Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this. STUDY REGISTRATION: PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup/.

Needs analysis (NA) is an information gathering process that is implemented to identify the learners’ needs for learning a language so that they would be taught the relevant materials. Moreover, NA is a very important procedure before designing teaching materials for English for Specific Purposes. For the current study, the NA framework that the present researcher developed was based on the available NA literatures, which were used to explore the views about English for Nursing Purposes (ENP) needs of the nursing undergraduates. Moreover, one of the key objectives of this study was to find out how the foundation year programme prepares the nursing students for their nursing studies.
This empirical research was conducted in a nursing college and in an English language institute in a one university in Saudi Arabia. The study was informed by the interpretive paradigm and based on a case study methodology utilising mixed methods (semi-structured interviews and questionnaires) to investigate nursing students’ needs. The initial phase of data collection was based on conducting semi- structured interviews with five English language teachers, five nursing teachers and five nursing students. The subsequent quantitative phase involved administering a questionnaire among of three groups of participants: 62 nursing students, 24 nursing tutors and 42 English language teachers (128 participants in total). The interviews were analysed qualitatively using thematic analysis, reviewing responses, grouping related responses and identifying common themes. Moreover, the questionnaires were analysed quantitatively using SPSS (Statistical Package for Social Sciences) version 24.0.
The qualitative and quantitative findings revealed that English is extensively used both in nursing studies and future career. The findings showed that the nature of English language course that taught in the foundation year program before joining the nursing college was not adequate to prepare the nursing students to meet their academic and professional needs. The overall findings of the study revealed the great need for the implementation of an ENP course in the current nursing college. On the basis of the results of this study, both nursing tutors and English language teachers expressed their willingness for collaborative teaching to make the ENP courses constructively associated with the students’ academic specialisations.

Background:
Antibiotics are drugs that are used to treat infections caused by bacteria. Approximately one third of hospital inpatients are prescribed an antibiotic at some point during their hospital stay. Prescribing errors contribute to many patient safety incident reports with some degree of prescribing error affecting up to 50% of hospital admissions.

Gentamicin is one of the most frequently prescribed aminoglycoside antibiotics in UK hospitals. However, despite its common use in clinical practice, it is challenging to prescribe due to its low oral bioavailability and a narrow therapeutic index. The evidence basis for prescribing is limited and consequently each Hospital Trust in the UK has developed their own individual prescribing protocol.

Aim:
To explore two distinct protocols for prescribing gentamicin in hospital settings, in order to understand the mechanisms they trigger and the outcomes they achieve.

Objective 1: to elicit an initial Programme Theory (IPT) by analysis of the protocols that articulate the intended process of gentamicin prescribing in the two hospital settings (Phase 1)

Objective 2: to test the IPT using empirical data from a mixed methods study in order to identify the important contexts, mechanisms and outcomes associated with the actual process of gentamicin prescribing (Phase 2)

Objective 3: to refine the Programme Theory in order to understand what works (outcome) as well as how (mechanisms) and under what conditions (context) in terms of gentamicin prescribing in the hospital setting (Phase 3)

Methods:
This study was a realist evaluation and was conducted in three phases: IPT generation, testing and refinement (as stated above).

We used a mixed methods approach to collect the empirical data. The quantitative data collection was in the form of a clinical audit reviewing the ‘accuracy’ of gentamicin prescribing at each site. A secondary purpose of the audit was to assess clinical outcomes and provide quantitative data to triangulate with our qualitative data sources in order to support our theories. The clinical audit commenced at the same time as the initial programme theory was developed and continued alongside the qualitative research. The qualitative research involved semi-structured audio-recorded interviews of healthcare professionals’ experiences of prescribing gentamicin. The qualitative and quantitative data were analysed together and integrated. The RAMESES II reporting standards and COREQ checklist were followed to ensure standards of research were maintained.

Results:
30 participants were recruited for interview. Participants included nursing staff, all grades of doctor and pharmacists. The final audit data set consisted of 100 prescribing episodes: 67 data sets from Site 1 and 33 data sets from Site 2.

We developed the IPT from analysis of the local policies for gentamicin prescribing. This allowed us to detail the ‘intended’ process of gentamicin prescribing and identify what appeared to be important contexts, mechanisms and outcomes in this process. The outcomes we were concerned with included: adherence (or not) to protocol and appropriate dosing.

The clinical audit found that prescribing at Site 2 adhered more closely to Trust protocol. The mean accuracy of gentamicin prescribing at Site 2 was 78.79 %; Site 1 was 65.67 %. The audit results were found to be significant with a p-value of 0.0038 when a two-tailed T-test was completed in Excel.

On review of renal function, seven patients at Site 1 and one patient at Site 2 developed an acute kidney injury (AKI). of the 8 patients that developed an AKI, 5 had received what was deemed a ‘safe’ (accurate) dose of gentamicin, 2 of the patients had been under-dosed and 1 received too large a dose.

With the data from our mixed methods study we were able to refine our IPT and develop the final Programme Theory. The audit data supported the suggested mechanisms. For example: fear of side effects related to gentamicin leads to under-dosing.6,7 all participants at both sites made reference to concerns about gentamicin and the possibility of nephrotoxicity. This leads to cautious prescribing which is more likely to under-dose: Site 1: 24% under-dosed, 10% over-dosed; Site 2: 12% under-dosed 9% over-dosed.

The key contexts we noted included: clinician experience; length and prescriptiveness of protocol; availability of patient information; complexity of calculations; involvement of multiple individuals to acquire all relevant data; involvement of different teams. The important mechanisms included: fear of outcomes (such as incorrect dose, damage to kidneys, delay in prescribing in unwell patients); frustration; concern; and confidence.

Conclusions:
This realist evaluation explored two distinct protocols to prescribing gentamicin in hospital settings. We have identified key contexts (such as properties of the prescribing protocol, the prescribing environment, clinician experience) that trigger hidden mechanisms (uncertainty, fear, confidence and frustration). and these can lead to both the intended outcome of adherence to the prescribing protocol, but also unintended outcomes: intentional deviation from the protocol, unintentional non-adherence and unnecessary gentamicin levels being taken.

Our data suggests that a simplified prescribing protocol for gentamicin is better received by those involved in the process of prescribing and leads to both better adherence to protocol and more accurate prescribing.

CONTEXT: it seems logical to suggest that investing in educators will lead to improved educational outcomes. However, in the case of faculty development, it is unclear how these benefits arise and decisions about investment typically have little basis in evidence. The aim of this realist evaluation was to understand the mechanisms by which investment in faculty development may lead to improved educational outcomes for staff and students. METHODS: This realist evaluation involved three phases: the development of an initial programme theory based on existing peer-reviewed literature (Phase 1), which was used within 32 realist interviews with key stakeholders at 17 UK medical schools (Phase 2), to underpin the creation of a series of recommendations for faculty development programme designers (Phase 3). RESULTS: the findings highlighted the complex and heterogeneous nature of faculty development programmes. Programme developers must consider a range of contexts (accreditation, meeting educational needs, learning culture, accessibility and interactivity) that can impact faculty members in variable ways (engagement, sense of value and belonging, motivation, reassurance and building relationships), potentially resulting in a range of staff outcomes (improved competence, satisfaction, confidence, faculty member collaboration and curriculum changes) that may ultimately benefit students. The improved understanding resulting from Phases 1 and 2, and the recommendations from Phase 3, will enable the design and tailoring of new and existing faculty development initiatives. CONCLUSIONS: This study deepens our understanding of the role of context in faculty development through the realist methodology employed and extends pre-existing knowledge to provide insights into evidence-based interventional strategies that may be effective. In particular, faculty development leads need to develop a clear implementation strategy, improve transparency of cashflow, establish effective formal or informal communication systems and evaluate the efficacy of their faculty development initiatives.

CONTEXT: the prevalence of stress, burnout and mental health disorders in medical students and doctors is high. It has been proposed that there may be an association between levels of tolerance of ambiguity (ie an ability to tolerate a lack of reliable, credible or adequate information) in clinical work and psychological well-being within this population. The aims of this systematic review were: (i) to assess the nature and extent of the literature available, in order to determine if there is an association, and (ii) to develop a conceptual model proposing possible mechanisms to underpin any association, in order to inform subsequent research. METHODS: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO databases were searched for articles published from inception to September 2018. Additional literature was identified by searching the reference lists of included articles, forward searches of included articles, hand searches of key journals and a grey literature search. of the 671 studies identified, 11 met the inclusion criteria. A qualitative synthesis of included studies was performed. RESULTS: all 11 included studies reported an association between a lower level of tolerance of ambiguity or uncertainty and reduced psychological well-being. Included studies were heterogeneous in terms of population and measurement approach, and were often of low methodological quality. Subsets of items from previously developed scales were often used without sufficient consideration of the impact of new combinations of items on scale validity. Similar scales were also scored inconsistently between studies, making comparison difficult. CONCLUSIONS: There appears to be an association between tolerance of ambiguity and psychological well-being. This provides new opportunities to understand and prevent the development of stress, burnout and mental health disorders in medical students and doctors. The conceptual model developed provides a framework for future research, which we hope will prevent wasted research effort through duplication and promote higher methodological quality.

BACKGROUND: Surgical specialities use extensive amounts of antimicrobials, and misuse has been widely reported, making them a key target for antimicrobial stewardship initiatives. Interventions informed by, and tailored to, a clear understanding of the contextual barriers to appropriate antimicrobial use are more likely to successfully improve practice. However, this approach has been under utilised. Our aim is to synthesise qualitative studies on surgical antimicrobial prescribing behaviour (APB) in hospital settings to explain how and why contextual factors act and interact to influence APB amongst surgical teams. We will develop new theory to advance understanding and identify knowledge gaps to inform further research. METHODS: the meta-ethnography will follow the seven-phase method described by Noblit and Hare. We will conduct a comprehensive search using eight databases (AMED, CINAHL, EMBASE, MEDLINE, MEDLINE-in-process, Web of Science, Cochrane Library and PsycINFO) with no date restrictions; forwards and backwards citation searches; and contacting first authors of relevant papers. Studies will be dual screened and included if they use recognised qualitative methods and analysis; focus on contextual factors associated with surgical APB within hospital settings; are available in full in English; and are relevant to the research question. Any disagreements between reviewers will be resolved through discussion to reach consensus. Included studies will be read repeatedly to illuminate key concepts and the relationship between key concepts across studies. Then, key concepts will be sorted into conceptual categories or 'piles' which will be further abstracted to form a conceptual framework explaining surgical APB. During the synthesis, emerging interpretations will be discussed with stakeholders (including authors of included studies where possible; surgical and stewardship practitioners; and patient representatives) to ensure new knowledge is meaningful. DISCUSSION: This research has several strengths: (1) the protocol has been written with reference to established guidance maximising rigour and transparency; (2) the multi-disciplinary research team bring varied interpretative repertoires and relevant methodological skills; and (3) stakeholders will be involved to ensure that findings are relevant, and disseminated via suitable channels, to support improved patient care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020184343.

CONTEXT: Both newly qualified doctors and teachers operate within ‘hot action’ environments, responding to constantly changing demands, and balancing routine responses against deliberate reflection. First-year transitions are particularly crucial, as these new professionals face steep learning curves and increased stress levels which can lead to poor mental health, burnout and attrition. This represents a loss of societal investment and negatively impacts upon student and patient outcomes. We know that the workplace is an important site of learning, where informal support from colleagues can aid transitions and professional development. Cross-professional comparisons are an under-used tool, which can shed light on parallels and divergences between different professional contexts, and help identify the features of workplaces which make them more supportive.

METHODS: a comparative research design was conducted in three integrated stages, to explore narrative data from early-career professionals in both medicine and education. First, a systematic secondary analysis of interviews and audio diaries, from 52 UK doctor participants in their first year of foundation training (F1s), to explore who provided informal workplace support, the types of support provided and factors influencing this. Secondly, collection and analysis of new narrative interviews with 11 newly qualified teachers (NQTs) working in English secondary schools, also exploring the support they received from others. Lastly, a comparative analysis of these findings to explore similarities and differences in support for these two professions, and identify over-arching factors which influence support seeking and provision for new professionals in ‘hot action’ workplaces. The main theoretical influence underpinning this analysis was that of structure and agency, which shaped the development of models of workplace support for newly qualified professionals so as to include a consideration of how the various features of workplace environments might enable or constrain individual agency.

RESULTS: the medical data analysis uncovered many additional support sources for F1s, including nurses, pharmacists, microbiologists, peers and near-peers, and a range of allied healthcare staff. These allowed F1s to draw upon different pools of expertise and experience, given difficulties accessing senior support. NQTs often drew support from allocated mentors and seniors within subject departments, but some also obtained support from allied staff such as TAs, behavioural and learning support staff, or through wider teaching networks including those facilitated by social media. Support from colleagues for F1s and NQTs included: information and advice on practice, orientation to local settings, collaborative development activities, observation and feedback, and socioemotional support. Some common barriers to support were the variability of departmental cultures, limited opportunities for informal contact, and negative inter-group perceptions. However, a number of stories described how novices overcame barriers through agentic action, such as seeking support from alternative sources. A model of workplace support was devised which summarises the features of workplace environments which might influence the seeking and provision workplace support, at the level of the individual, social, organisational and material. This model might be tested within similar ‘hot-action’ workplace environments, used as a tool for future research, or to evaluate the extent to which specific workplace environments facilitate support for new professionals.

CONCLUSIONS: in both professional contexts, supportive working relationships could be enhanced through broad strategies which aim to break down barriers, build relationships, create environments of trust and cultivate professional agency. Such measures might include: greater utilisation of existing knowledge sources such as near-peers and allied staff; improved role understanding and better communication with specialised staff; creating opportunities for informal contact via shared social spaces, events and training; and communicating via professional education the successful strategies used by previous early-career professionals to meet their support needs. Future research might further explore the features which underlie positive local cultures of supportivity, as well as developing ecological or whole-systems approaches to understanding workplace support.

INTRODUCTION: the decision-making process for students as to which medical schools to apply to is open to many factors and influences. Research has identified several factors which influence prospective students' choice of medical school and career. There is also evidence that websites and prospectuses may be creating potential barriers to widening access. METHODS: the websites and prospectuses of 33 medical schools in the United Kingdom were searched for relevant images. These images and the people in them were subjected to inclusion/exclusion criteria. Data about the images and people were recorded so that a content analysis could be performed. The relative proportions were compared with pre-existing data relating to the medical profession and society. RESULTS: from 33 medical schools, 650 images were included, with 1,817 people depicted. The largest group for the assumed roles was 'student', as expected, with 1,423 people (78%). For the overall theme of the image, community placement themed images made up only 2% of images (14) and hospital placement themed images made up 24% (154). Chi-squared goodness of fit showed statistically significant results for most groups of data when comparing ethnicity, the overall theme of the image and assumed specialty group, but not when comparing gender. DISCUSSION: in conclusion, for gender, medical schools are accurately reflecting national data. However, for ethnicity medical schools fail to accurately represent national data, leading to incorrect signalling about the ethnic makeup of their students. Additionally, medical schools are signalling to students a strong preference for hospital-based settings, despite a strong national drive to recruit more general practitioners.

The 'How to …' series focuses on how to do qualitative research. But how can qualitative research enhance patient care? This paper aims to support health care practitioners, educators and researchers who are interested in bridging the gap between research and practice (both clinical and educational), to guide improvements that can ultimately benefit patients. We present action research and the Change Laboratory method as two approaches that typically involve qualitative research and have potential to change practice, blending scientific inquiry with social action. These approaches establish close research-practice partnerships and help answer tricky 'why' and 'how' questions that may unlock deep insights to enhance learning and patient care. … how can qualitative research enhance patient care?

BACKGROUND: Mental health problems are prevalent amongst medical students. However, many students delay seeking medical help or support from the medical school for a variety of reasons, including a fear of facing fitness to practice proceedings. Tackling this problem of awareness and delayed presentation will need a strong and dedicated focus at all stages, with prevention being of great importance. METHODS: a conference dedicated to mental health and well-being was organised for students of all years. The first part of the conference centred on well-being dilemmas and the second part focused on discussing important issues in small group sessions. RESULTS: Students were divided into eight groups and each group suggested improvements to the course that they felt would improve mental health and well-being. The main suggestions raised were: reassurance that the disclosure of mental health problems would not automatically result in fitness to practice proceedings; separate academic and pastoral roles of tutors; open up the topic of mental health and well-being more frequently during the programme; improve knowledge about the availability of support services; and have mentors who are at an earlier stage in postgraduate training (e.g. junior doctors). DISCUSSION: it is necessary to tackle the prevalent myths about this topic. Many students are unaware of the support services available. This conference has therefore sought to increase awareness of the topic. An approach is also now needed to identify those who need extra help. The authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference, for example. Many students are unaware of the support services available the authors strongly advocate opening up this topic throughout the course in the context of a dedicated conference ….

Context: Meta-analyses have shown that feedback can be a powerful intervention to increase learning and performance but there is significant variability in impact. New trials are adding little to the question of whether feedback interventions are effective, so the focus now is how to optimise the effect. Early career professionals (ECPs) in busy work environments are a particularly important target group. This literature review aimed to synthesise information to support the optimal design of feedback interventions for ECPs. Methods: We undertook a scoping literature review, using search terms such as ‘feedback’ and ‘effectiveness’ in MEDLINE, MEDLINE-In-Process, PsycINFO, CINAHL, Education Research Complete, Education Resources Information Center, the Cochrane Database of Systematic Reviews, the Social Sciences Citation Index and Applied Social Sciences Index and Abstracts, to identify empirical studies describing feedback interventions in busy workplaces published in English since 1990. We applied inclusion criteria to identify studies for the mapping stage and extracted key data to inform the next stage. We then selected a subset of papers for the framework development stage, which were subjected to a thematic synthesis by three authors, leading to a new feedback framework and a modified version of feedback intervention theory specifically for ECPs. Results: a total of 80 studies were included in the mapping stage, with roughly equal studies from hospital settings and school classrooms, and 17 papers were included in the framework development stage. The feedback framework comprised three main categories (audit, feedback and goal setting) and 22 subcategories. The review highlighted the limited empirical research focusing solely on feedback for ECPs, which was surprising given the particular nuances in feedback for ECPs identified through this study. Conclusions: We offer the feedback framework to optimise the design of future feedback interventions for early career professionals and encourage future feedback research to move away from generic models and tailor work to specific target audiences.

AIMS: to develop and evaluate a feasible, authentic pharmacist-led prescribing feedback intervention for doctors-in-training, to reduce prescribing errors. METHODS: This was a mixed methods study. Sixteen postgraduate doctors-in training, rotating though the surgical assessment unit of 1 UK hospital, were filmed taking a medication history with a patient and prescribing medications. Each doctor reviewed their video footage and made plans to improve their prescribing, supported by feedback from a pharmacist. Quantitative data in the form of prescribing error prevalence data were collected on 1 day per week before, during and after the intervention period (between November 2015 and March 2017). Qualitative data in the form of individual semi-structured interviews were collected with a subset of participants, to evaluate their experience. Quantitative data were analysed using a statistical process chart and qualitative data were transcribed and analysed thematically. RESULTS: During the data collection period, 923 patient drug charts were reviewed by pharmacists who identified 1219 prescribing errors overall. Implementation of this feedback approach was associated with a statistically significant reduction in the mean number of prescribing errors, from 19.0/d to 11.7/d (estimated to equate to 38% reduction; P 

INTRODUCTION: Prescribing antibiotics is an error-prone activity and one of the more challenging responsibilities for doctors in training. The nature and extent of challenges experienced by them at different stages of the antibiotic prescribing process are not well described, meaning that interventions may not target the most problematic areas. OBJECTIVES: Our aim was to explore doctors in training experiences of common problems in the antibiotic prescribing process using cultural-historical activity theory (CHAT). Our research questions were as follows: What are the intended stages in the antibiotic prescribing process? What are the challenges and where in the prescribing process do these occur? METHODS: We developed a process model based on how antibiotic prescribing is intended to occur in a 'typical' National Health Service hospital in the UK. The model was first informed by literature and refined through consultation with practising healthcare professionals and medical educators. Then, drawing on CHAT, we analysed 33 doctors in training narratives of their antibiotic prescribing experiences to identify and interpret common problems in the process. RESULTS: Our analysis revealed five main disturbances commonly occurring during the antibiotic prescribing process: consultation challenges, lack of continuity, process variation, challenges in patient handover and partial loss of object. Our process model, with 31 stages and multiple practitioners, captures the complexity, inconsistency and unpredictability of the process. The model also highlights 'hot spots' in the process, which are the stages that doctors in training are most likely to have difficulty navigating. CONCLUSIONS: Our study widens the understanding of doctors in training prescribing experiences and development needs regarding the prescribing process. Our process model, identifying the common disturbances and hot spots in the process, can facilitate the development of antibiotic prescribing activities and the optimal design of interventions to support doctors in training.

The importance of emotions within medical practice is well documented. Research suggests that how clinicians deal with negative emotions can affect clinical decision-making, health service delivery, clinician well-being, attentiveness to patient care and patient satisfaction. Previous research has identified the transition from student to junior doctor (intern) as a particularly challenging time. While many studies have highlighted the presence of emotions during this transition, how junior doctors manage emotions has rarely been considered. We conducted a secondary analysis of narrative data in which 34 junior doctors, within a few months of transitioning into practice, talked about situations for which they felt prepared or unprepared for practice (preparedness narratives) through audio diaries and interviews. We examined these data deductively (using Gross' theory of emotion regulation: ER) and inductively to answer the following research questions: (RQ1) what ER strategies do junior doctors describe in their preparedness narratives? and (RQ2) at what point in the clinical situation are these strategies narrated? We identified 406 personal incident narratives: 243 (60%) contained negative emotion, with 86 (21%) also containing ER. Overall, we identified 137 ER strategies, occurring prior to (n = 29, 21%), during (n = 74, 54%) and after (n = 34, 25%) the situation. Although Gross' theory captured many of the ER strategies used by junior doctors, we identify further ways in which this model can be adapted to fully capture the range of ER strategies participants employed. Further, from our analysis, we believe that raising medical students' awareness of how they can handle stressful situations might help smooth the transition to becoming a doctor and be important for later practice.

Aim: to understand the experiences of students and problem-based learning (PBL) facilitators during an evidence-based curriculum change to a PBL programme within an undergraduate medical course in South West England. Methods: Four novel PBL cases were designed and implemented, based on educational theory and evidence. Eight focus groups were undertaken with Year-1 and -2 students (n = 18) and PBL facilitators (n = 14) to explore the experiences of participants. Thematic analysis and conceptual abstraction led to insights into the intended and unintended consequences of the change. Results: Participant responses to the change process were influenced by the perceived relevance and value of the change (e.g. benefit to student learning), which was shaped by individual beliefs and preferences (e.g. presumed purpose of PBL, relative value placed on different curriculum topics, and desire for uniform educational experience), and the wider education context (e.g. expectations of assessment). It appears that the three distinct elements must align for the changes to be received positively. We updated our PBL curriculum in response to new evidence. Discussion: This study describes how we updated our PBL curriculum in response to new evidence, and demonstrates the importance of communicating the pedagogic rationale behind changes, and meticulous planning, preparation and alignment, even in distant parts of the curriculum. Engaging with existing views and attitudes is an essential requirement for successful curriculum change.

This paper, on writing research questions, is the first in a series that aims to support novice researchers within clinical education, particularly those undertaking their first qualitative study. Put simply, a research question is a question that a research project sets out to answer. Most research questions will lead to a project that aims to generate new insights, but the target audience and the methodology will vary widely. The term ‘evaluation question’ is used less commonly, but the same principles apply. The key difference is that evaluation questions are typically more focused on the immediate context: for example, the effectiveness of an educational intervention in a particular setting. Whether your ambition is for research or evaluation, we hope that you will find this paper helpful for designing your own educational projects. A research question is a question that a research project sets out to answer.

Objective While previous studies have begun to explore newly graduated junior doctors' preparedness for practice, findings are largely based on simplistic survey data or perceptions of newly graduated junior doctors and their clinical supervisors alone. This study explores, in a deeper manner, multiple stakeholders' conceptualisations of what it means to be prepared for practice and their perceptions about newly graduated junior doctors' preparedness (or unpreparedness) using innovative qualitative methods. Design a multistakeholder, multicentre qualitative study including narrative interviews and longitudinal audio diaries. Setting Four UK settings: England, Northern Ireland, Scotland and Wales. Participants Eight stakeholder groups comprising n=185 participants engaged in 101 narrative interviews (27 group and 84 individual). Twenty-six junior doctors in their first year postgraduation also provided audio diaries over a 3-month period. Results We identified 2186 narratives across all participants (506 classified as 'prepared', 663 as 'unprepared', 951 as 'general'). Seven themes were identified; this paper focuses on two themes pertinent to our research questions: (1) explicit conceptualisations of preparedness for practice; and (2) newly graduated junior doctors' preparedness for the General Medical Council's (GMC) outcomes for graduates. Stakeholders' conceptualisations of preparedness for practice included short-term (hitting the ground running) and long-term preparedness, alongside being prepared for practical and emotional aspects. Stakeholders' perceptions of medical graduates' preparedness for practice varied across different GMC outcomes for graduates (eg, Doctor as Scholar and Scientist, as Practitioner, as Professional) and across stakeholders (eg, newly graduated doctors sometimes perceived themselves as prepared but others did not). Conclusion Our narrative findings highlight the complexities and nuances surrounding new medical graduates' preparedness for practice. We encourage stakeholders to develop a shared understanding (and realistic expectations) of new medical graduates' preparedness. We invite medical school leaders to increase the proportion of time that medical students spend participating meaningfully in multiprofessional teams during workplace learning.

Current guidelines suggest that educators in both medical and veterinary professions should do more to ensure that students can tolerate ambiguity. Designing curricula to achieve this requires the ability to measure and understand differences in ambiguity tolerance among and within professional groups. Although scales have been developed to measure tolerance of ambiguity in both medical and veterinary professions, no comparative studies have been reported. We compared the tolerance of ambiguity of medical and veterinary students, hypothesizing that veterinary students would have higher tolerance of ambiguity, given the greater patient diversity and less wellestablished evidence base underpinning practice. We conducted a secondary analysis of questionnaire data from first-to fourth-year medical and veterinary students. Tolerance of ambiguity scores were calculated and compared using the TAMSAD scale (29 items validated for the medical student population), the TAVS scale (27 items validated for the veterinary student population), and a scale comprising the 22 items common to both scales. Using the TAMSAD and TAVS scales, medical students had a significantly higher mean tolerance of ambiguity score than veterinary students (56.1 vs. 54.1, p <. 001 and 60.4 vs. 58.5, p =. 002, respectively) but no difference was seen when only the 22 shared items were compared (56.1 vs. 57.2, p =. 513). The results do not support our hypothesis and highlight that different findings can result when different tools are used. Medical students may have slightly higher tolerance of ambiguity than veterinary students, although this depends on the scale used.

Objective to understand how prepared UK medical graduates are for practice and the effectiveness of workplace transition interventions. Design a rapid review of the literature (registration #CRD42013005305). Data sources Nine major databases (and key websites) were searched in two timeframes (July-September 2013; updated May-June 2014): CINAHL, Embase, Educational Resources Information Centre, Health Management Information Consortium, MEDLINE, MEDLINE in Process, PsycINFO, Scopus and Web of Knowledge. Eligibility criteria for selecting studies Primary research or studies reporting UK medical graduates' preparedness between 2009 and 2014: manuscripts in English; all study types; participants who are final-year medical students, medical graduates, clinical educators, patients or NHS employers and all outcome measures. Data extraction at time 1, three researchers screened manuscripts (for duplicates, exclusion/inclusion criteria and quality). Remaining 81 manuscripts were coded. At time 2, one researcher repeated the process for 2013-2014 (adding six manuscripts). Data were analysed using a narrative synthesis and mapped against Tomorrow's Doctors (2009) graduate outcomes. Results Most studies comprised junior doctors' self-reports (65/87, 75%), few defined preparedness and a programmatic approach was lacking. Six themes were highlighted: individual skills/knowledge, interactional competence, systemic/technological competence, personal preparedness, demographic factors and transitional interventions. Graduates appear prepared for history taking, physical examinations and some clinical skills, but unprepared for other aspects, including prescribing, clinical reasoning/diagnoses, emergency management, multidisciplinary team-working, handover, error/safety incidents, understanding ethical/legal issues and ward environment familiarity. Shadowing and induction smooth transition into practice, but there is a paucity of evidence around assistantship efficacy. Conclusions Educational interventions are needed to address areas of unpreparedness (eg, multidisciplinary team-working, prescribing and clinical reasoning). Future research in areas we are unsure about should adopt a programmatic and rigorous approach, with clear definitions of preparedness, multiple stakeholder perspectives along with multisite and longitudinal research designs to achieve a joined-up, systematic, approach to understanding future educational requirements for junior doctors.

© the Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. Background: Antimicrobial resistance has led to widespread implementation of interventions for appropriate prescribing. However, such interventions are often adopted without an adequate understanding of the challenges facing doctors-in-training as key prescribers. Methods: the review followed a realist, theory-driven approach to synthesizing qualitative, quantitative and mixed-methods literature. Consistent with realist review quality standards, articles retrieved from electronic databases were systematically screened and analysed to elicit explanations of antimicrobial prescribing behaviours. These explanations were consolidated into a programme theory drawing on social science and learning theory, and shaped though input from patients and practitioners. Results: By synthesizing data from 131 articles, the review highlights the complex social and professional dynamics underlying antimicrobial prescribing decisions of doctors-in-training. The analysis shows how doctors-intraining often operate within challenging contexts (hierarchical relationships, powerful prescribing norms, unclear roles and responsibilities, implicit expectations about knowledge levels, uncertainty about application of knowledge in practice) where they prioritize particular responses (fear of criticism and individual responsibility, managing one's reputation and position in the team, appearing competent). These complex dynamics explain how and why doctors-in-training decide to: (i) follow senior clinicians' prescribing habits; (ii) take (or not) into account prescribing aids, advice from other health professionals or patient expectations; and (iii) ask questions or challenge decisions. This increased understanding allows for targeted tailoring, design and implementation of antimicrobial prescribing interventions. Conclusions: This review contributes to a better understanding of how antimicrobial prescribing interventions for doctors-in-training can be embedded more successfully in the hierarchical and inter-professional dynamics of different healthcare settings.

OBJECTIVES: the Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis. SETTING: Four UK study sites, one in each country. PARTICIPANTS: 185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25). RESULTS: We identified four main themes: (1) the F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal. CONCLUSIONS: a policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Aim: Little is known about the determinants of antimicrobial prescribing behaviour (APB), how they vary between hospital prescribers or the mechanism by which interventions are effective. Yet, interventions based on a sound theoretical understanding of APB are more likely to be successful in changing outcomes. This study sought to quantify the potential determinants of APB among hospital doctors in south-west England. Methods: This multicentre, quantitative study employed a closed answer questionnaire to garner hospital doctors' views on factors influencing their APB. Underlying constructs within the data were identified using exploratory factor analysis and subsequent pairwise comparisons assessed for variance between groups of prescribers. Results: the questionnaire was completed by 301 doctors across four centres (response rate ≥ 74%) and three key factors were identified: autonomy, guidelines adherence and antibiotic awareness. The internal consistency for the questionnaire scale and for each factor subscale was good (α ≥ 0.7). Subgroup analysis identified significant differences between groups of prescribers: autonomy scores increased with grade until at the specialist trainee level (P ≤ 0.009), foundation doctors scored higher for guidelines adherence than consultants (P = 0.004) and specialist trainees (P = 0.003) and United Kingdom trained doctors scored higher than those trained abroad for antibiotic awareness (P 

OBJECTIVE: New medical graduates are the front-line staff in many hospital settings and manage patients with diabetes frequently. Prescribing is an area of concern for junior doctors, however, with insulin prescribing reported as a particular weakness. This study aimed to produce an educational intervention which aimed to improve preparedness to manage patients with diabetes and evaluate it using a mixed methods approach. RESEARCH DESIGN AND METHODS: an e-resource (http://www.diabetesscenariosforjuniordoctors.co.uk) was created to contain commonplace and authentic diabetes decision-making scenarios. -32 junior doctors (n=20) and year 5 students (n=12) in South West England worked through the scenarios while 'thinking aloud' and then undertook a semistructured interview. Qualitative data were transcribed verbatim and analyzed thematically. Participant confidence to manage patients with diabetes before, immediately after, and 6â€
weeks after the educational intervention was also measured using a self-rating scale. RESULTS: Participants reported that patients with diabetes were daunting to manage because of the wide array of insulin products, their lack of confidence with chronic disease management and the difficulty of applying theory to practice. The e-resource was described as authentic, practical, and appropriate for the target audience. Junior doctors' self-rated confidence to manage patients with diabetes increased from 4.7 (of 10) before using the e-resource, to 6.4 immediately afterwards, and 6.8 6â€
weeks later. Medical students' confidence increased from 5.1 before, to 6.4 immediately afterwards, and 6.4 6â€
weeks later. CONCLUSIONS: Providing opportunities to work with authentic scenarios in a safe environment can help to ameliorate junior doctors' lack of confidence to manage patients with diabetes.

INTRODUCTION: Antimicrobial resistance has been described as a global crisis-more prudent prescribing is part of the solution. Behaviour change interventions are needed to improve prescribing practice. Presently, the literature documents that context impacts on prescribing decisions, yet insufficient evidence exists to enable researchers and policymakers to determine how local tailoring should take place. Doctors in training are an important group to study, being numerically the largest group of prescribers in UK hospitals. Unfortunately very few interventions specifically targeted this group. METHODS AND ANALYSIS: Our project aims to understand how interventions to change antimicrobial prescribing behaviours of doctors in training produce their effects. We will recruit a project stakeholder group to advise us throughout. We will synthesise the literature using the realist review approach-a form of theory-driven interpretive systematic review approach often used to make sense of complex interventions. Interventions to improve antimicrobial prescribing behaviours are complex-they are context dependent, have long implementation chains, multiple non-linear interactions, emergence and depend on human agency. Our review will iteratively progress through 5 steps: step 1--Locate existing theories; step 2--Search for evidence; step 3--Article selection; step 4--Extracting and organising data; and step 5--Synthesising the evidence and drawing conclusions. Data analysis will use a realist logic of analysis to describe and explain what works, for whom, in what circumstances, in what respects, how and why to improve antimicrobial prescribing behaviour of doctors in training. ETHICS AND DISSEMINATION: Ethical approval was not required for our review. Our dissemination strategy will be participatory and involve input from our stakeholder group. Tailored project outputs will be targeted at 3 audiences: (1) doctors in training; (2) clinical supervisors/trainers and medical educators; and (3) policy, decision makers, regulators and royal societies.

OBJECTIVE: Medical students experience higher prevalence of mental illness than age-matched controls and are less likely to access appropriate help when this happens. The aim of this study was to determine the range of strategies deployed by medical schools to support medical students with mental health concerns and to use this to identify distinct categories. METHODS: Websites and documents relating to all 32 UK medical schools were looked at, as were reports for quality assurance visits carried out by the General Medical Council (UK). A structured telephone interview was carried out with medical schools. Support services were examined by tracing the path that might be taken by a hypothetical student with mental health concerns of varying severity, seeing what was required and what was available at each stage. RESULTS: a range of support strategies is available to most medical students both from their medical school and from generic services in the university. Medical students will usually first contact a personal tutor or a senior member of faculty or be contacted by them as a result of concerns raised either via performance issues or by another student. While individual support interventions are mostly based on evidence of effectiveness, there is no unifying theory in terms of what constitutes effective support. To enable analysis of support interventions and comparison across providers, a six-stage conceptual model of prevention was developed. The six stages are the following: prevention, identification, referral, escalation, treatment, and reintegration. CONCLUSIONS: the staged model, derived from analysis of existing interventions, provides a framework for evaluation of current provision and comparison of different methods of delivery. Moreover, it provides a framework for future research.

OBJECTIVES: Prescribing medications is an important challenge in the transition to junior doctor practice. We explored the antimicrobial prescribing experiences of foundation year (FY) doctors in two UK hospitals. The study answers three research questions: (i) What types of antimicrobial prescribing experiences do FY doctors have?; (ii) How do they make sense of their antimicrobial prescribing experiences?; and (iii) What are their educational needs regarding antimicrobial prescribing? METHODS: a narrative interview study involving 33 FY1 and FY2 doctors in two UK hospitals (Location 1, England and Location 2, Scotland) was undertaken. Complementary analytical approaches to answer the research questions, including framework analysis and in-depth narrative analysis, were employed. RESULTS: FY doctors made complicated antimicrobial prescribing decisions. The context in which these decisions took place was also challenging, with marked variability in practice between wards within the same hospital, conflicting advice given by senior staff and a dearth of supervision and feedback. In-depth narrative analysis illustrated a complex interplay between what trainees say and how they narrate their prescribing experiences. Three data-derived educational strategies were identified and presented to an Expert Reference Group and research participants for their feedback and ideas for development. CONCLUSIONS: the narrative approach provided a window into FY doctors' experiences that was wider than the antimicrobial prescribing experiences themselves. The FY doctors described complex tasks being undertaken in challenging environments, where workplace cultures often failed to promote learning and feedback and where hierarchy sometimes worked against rational antimicrobial prescribing. Some practical solutions to these challenges are offered.

The practice of medicine involves inherent ambiguity, arising from limitations of knowledge, diagnostic problems, complexities of treatment and outcome and unpredictability of patient response. Research into doctors' tolerance of ambiguity is hampered by poor conceptual clarity and inadequate measurement scales. We aimed to create and pilot a measurement scale for tolerance of ambiguity in medical students and junior doctors that addresses the limitations of existing scales. After defining tolerance of ambiguity, scale items were generated by literature review and expert consultation. Feedback on the draft scale was sought and incorporated. 411 medical students and 75 foundation doctors in Exeter, UK were asked to complete the scale. Psychometric analysis enabled further scale refinement and comparison of scale scores across subgroups. The pilot study achieved a 64% response rate. The final 29 item version of the Tolerance of Ambiguity in Medical Students and Doctors (TAMSAD) scale had good internal reliability (Cronbach's α 0.80). Tolerance of ambiguity was higher in foundation year 2 doctors than first, third and fourth year medical students (-5.23, P = 0.012; -5.98, P = 0.013; -4.62, P = 0.035, for each year group respectively). The TAMSAD scale offers a valid and reliable alternative to existing scales. Further work is required in different settings and in longitudinal studies but this study offers intriguing provisional insights.

Background: Learning to access information using resources such as books and search engines is an important and fast changing challenge for doctors and medical students. Many resources exist to support evidence-based clinical decision-making, but a wide range of factors influences their use. Objective: to explore qualified doctor and medical students' use of resources for accessing information and to determine what is used and why. Methods: a stratified sample of 46 participants was recruited in Devon, UK. Participants kept a self-report diary of resources used over a week. The diaries were then used to stimulate recall within a semi-structured interview. Diary data were collated into tables of resource use. Qualitative data from the interviews were transcribed verbatim and thematically analysed. Results: Many resources were used by participants but typically for a short duration of time. Categories of reasons for accessing resources were 'to check', 'to learn' and 'to demonstrate'. The two main factors influencing choice of information resource were 'ease of access' and 'quality of information'. Students accessed more information, for a longer duration. Discussion & Conclusion: Resources must be quick to use, easy to access and tailored to the different purposes that they serve for qualified doctors and medical students. © 2014 Health Libraries Group.

BACKGROUND: Learning to access information using resources such as books and search engines is an important and fast changing challenge for doctors and medical students. Many resources exist to support evidence-based clinical decision-making, but a wide range of factors influences their use. OBJECTIVE: to explore qualified doctor and medical students' use of resources for accessing information and to determine what is used and why. METHODS: a stratified sample of 46 participants was recruited in Devon, UK. Participants kept a self-report diary of resources used over a week. The diaries were then used to stimulate recall within a semi-structured interview. Diary data were collated into tables of resource use. Qualitative data from the interviews were transcribed verbatim and thematically analysed. RESULTS: Many resources were used by participants but typically for a short duration of time. Categories of reasons for accessing resources were 'to check', 'to learn' and 'to demonstrate'. The two main factors influencing choice of information resource were 'ease of access' and 'quality of information'. Students accessed more information, for a longer duration. DISCUSSION & CONCLUSION: Resources must be quick to use, easy to access and tailored to the different purposes that they serve for qualified doctors and medical students.

OBJECTIVES: to explore Foundation trainees' and trainers' understandings and experiences of supervised learning events (SLEs), compared with workplace-based assessments (WPBAs), and their suggestions for developing SLEs. DESIGN: a narrative interview study based on 55 individual and 19 group interviews. SETTING: UK-wide study across three sites in England, Scotland and Wales. PARTICIPANTS: Using maximum-variation sampling, 70 Foundation trainees and 40 trainers were recruited, shared their understandings and experiences of SLEs/WPBAs and made recommendations for future practice. METHODS: Data were analysed using thematic and discourse analysis and narrative analysis of one exemplar personal incident narrative. RESULTS: While participants volunteered understandings of SLEs as learning and assessment, they typically volunteered understandings of WPBAs as assessment. Trainers seemed more likely to describe SLEs as assessment and a 'safety net' to protect patients than trainees. We identified 333 personal incident narratives in our data (221 SLEs; 72 WPBAs). There was perceived variability in the conduct of SLEs/WPBAs in terms of their initiation, tools used, feedback and finalisation. Numerous factors at individual, interpersonal, cultural and technological levels were thought to facilitate/hinder learning. SLE narratives were more likely to be evaluated positively than WPBA narratives overall and by trainees specifically. Participants made sense of their experiences, emotions, identities and relationships through their narratives. They provided numerous suggestions for improving SLEs at individual, interpersonal, cultural and technological levels. CONCLUSIONS: Our findings provide tentative support for the shift to formative learning with the introduction of SLEs, albeit raising concerns around trainees' and trainers' understandings about SLEs. We identify five key educational recommendations from our study. Additional research is now needed to explore further the complexities around SLEs within workplace learning.

AIMS: Prescribing is a complex task and a high risk area of clinical practice. Poor prescribing occurs across staff grades and settings but new prescribers are attributed much of the blame. New prescribers may not be confident or even competent to prescribe and probably have different support and development needs than their more experienced colleagues. Unfortunately, little is known about what interventions are effective in this group. Previous systematic reviews have not distinguished between different grades of staff, have been narrow in scope and are now out of date. Therefore, to inform the design of educational interventions to change prescribing behaviour, particularly that of new prescibers, we conducted a systematic review of existing hospital-based interventions. METHODS: Embase, Medline, SIGLE, Cinahl and PsychINFO were searched for relevant studies published 1994-2010. Studies describing interventions to change the behaviour of prescribers in hospital settings were included, with an emphasis on new prescibers. The bibliographies of included papers were also searched for relevant studies. Interventions and effectiveness were classified using existing frameworks and the quality of studies was assessed using a validated instrument. RESULTS: Sixty-four studies were included in the review. Only 13% of interventions specifically targeted new prescribers. Most interventions (72%) were deemed effective in changing behaviour but no particular type stood out as most effective. CONCLUSION: Very few studies have tailored educational interventions to meet needs of new prescribers, or distinguished between new and experienced prescribers. Educational development and research will be required to improve this important aspect of early clinical practice.

Inventories that measure approaches to learning have revealed that certain approaches are associated with better academic performance. However, these inventories were developed primarily with higher education students on non-vocational courses and recent research shows they fail to capture the full range of healthcare students' intentions and motivations for learning. To develop a new inventory measuring approaches to learning that addresses these shortfalls and is relevant to students on vocational courses in healthcare. In depth interviews with healthcare students were performed to understand the full range of healthcare students' intentions and motivations. The data were used to create a draft inventory, which was reviewed by interview participants and then tested with medical students. The final inventory was piloted with 303 healthcare students across six disciplines. Exploratory factor analysis was used to identify groups of related items within the inventory. The research produced a 32 item scale based on rich qualitative data, with a four factor structure and good internal consistency. A desire to link theory and practice was a distinctive feature of healthcare students. The new inventory contains nuanced items that enable a better understanding of their common and distinctive intentions and motivations. This study suggests that healthcare student populations have some unique intentions and motivations for learning and therefore require a bespoke inventory to ensure that important aspects are not missed. It offers a new tool for meaningful future research, the Healthcare Learning and Studying Inventory (HLSI). © 2012 Springer Science+Business Media B.V.

Inventories that measure approaches to learning have revealed that certain approaches are associated with better academic performance. However, these inventories were developed primarily with higher education students on non-vocational courses and recent research shows they fail to capture the full range of healthcare students' intentions and motivations for learning. To develop a new inventory measuring approaches to learning that addresses these shortfalls and is relevant to students on vocational courses in healthcare. In depth interviews with healthcare students were performed to understand the full range of healthcare students' intentions and motivations. The data were used to create a draft inventory, which was reviewed by interview participants and then tested with medical students. The final inventory was piloted with 303 healthcare students across six disciplines. Exploratory factor analysis was used to identify groups of related items within the inventory. The research produced a 32 item scale based on rich qualitative data, with a four factor structure and good internal consistency. A desire to link theory and practice was a distinctive feature of healthcare students. The new inventory contains nuanced items that enable a better understanding of their common and distinctive intentions and motivations. This study suggests that healthcare student populations have some unique intentions and motivations for learning and therefore require a bespoke inventory to ensure that important aspects are not missed. It offers a new tool for meaningful future research, the Healthcare Learning and Studying Inventory (HLSI).

Previous debate has explored whether medical education research should become more like health services research in terms of frameworks, collaborations and methodologies. Notable recent changes in health services research include an increasing emphasis on complex interventions, defined as interventions that involve more than one component. The purpose of this study was to explore the extent of thinking about medical education as a complex intervention and to analyse medical education research to determine whether its collaborations and methodologies are becoming more like health services research. Research articles published in three journals over 2 years were analysed to determine the purpose of the research in relation to a framework for evaluating complex interventions, the degree of collaboration, and the methodology. Most studies aimed to develop theory or assess effectiveness and many categories of the complex interventions framework were not represented in the medical education research literature. Studies usually involved only one research site and were predominantly quantitative but not experimental or quasi-experimental. Whilst medical education research has not moved significantly in the direction of health services research over recent years, the complex interventions lens provided insights into why this might be so (namely the significant challenges associated with researching medical education). We recommend that medical education researchers work within a complex interventions framework and look to research fields with similar challenges (e.g. the study of chronic illness in a changing context) for ideas about theories, frameworks, methodologies and collaborations that can illuminate the field of medical education research. © 2012 Springer Science+Business Media Dordrecht.

Previous debate has explored whether medical education research should become more like health services research in terms of frameworks, collaborations and methodologies. Notable recent changes in health services research include an increasing emphasis on complex interventions, defined as interventions that involve more than one component. The purpose of this study was to explore the extent of thinking about medical education as a complex intervention and to analyse medical education research to determine whether its collaborations and methodologies are becoming more like health services research. Research articles published in three journals over 2 years were analysed to determine the purpose of the research in relation to a framework for evaluating complex interventions, the degree of collaboration, and the methodology. Most studies aimed to develop theory or assess effectiveness and many categories of the complex interventions framework were not represented in the medical education research literature. Studies usually involved only one research site and were predominantly quantitative but not experimental or quasi-experimental. Whilst medical education research has not moved significantly in the direction of health services research over recent years, the complex interventions lens provided insights into why this might be so (namely the significant challenges associated with researching medical education). We recommend that medical education researchers work within a complex interventions framework and look to research fields with similar challenges (e.g. the study of chronic illness in a changing context) for ideas about theories, frameworks, methodologies and collaborations that can illuminate the field of medical education research.

Background the Progress Test (PT) was developed to assess student learning within integrated curricula. Whilst it is effective in promoting and rewarding deep approaches to learning in some settings, we hypothesised that implementation of the curriculum (design and assessment) may impact on students' preparation for the PT and their learning. Aim to compare students' perceptions of and preparations for the PT at two medical schools. Method Focus groups were used to generate items for a questionnaire. This was piloted, refined, and then delivered at both schools. Exploratory factor analysis identified the main factors underpinning response patterns. ANOVA was used to compare differences in response by school, year group and gender. Results Response rates were 640 (57%) and 414 (47%) at Schools a and B, respectively. Three major factors were identified: the PT's ability to (1) assess academic learning (2) support clinical learning; (3) the PT's impact on exam preparation. Significant differences were found between settings. In the school with early clinical contact, more frequent PTs and no end of unit tests, students were more likely to appreciate the PT as a support for learning, perceive it as fair and valid, and use a deeper approach to learning-but they also spent longer preparing for the test. Conclusion Different approaches to the delivery of the PT can impact significantly on student study patterns. The learning environment has an important impact on student perceptions of assessment and approach to learning. Careful decisions about PT deployment must be taken to ensure its optimal impact. © 2011 Springer Science+Business Media B.V.

BACKGROUND: the Progress Test (PT) was developed to assess student learning within integrated curricula. Whilst it is effective in promoting and rewarding deep approaches to learning in some settings, we hypothesised that implementation of the curriculum (design and assessment) may impact on students' preparation for the PT and their learning. Aim to compare students' perceptions of and preparations for the PT at two medical schools. METHOD: Focus groups were used to generate items for a questionnaire. This was piloted, refined, and then delivered at both schools. Exploratory factor analysis identified the main factors underpinning response patterns. ANOVA was used to compare differences in response by school, year group and gender. RESULTS: Response rates were 640 (57%) and 414 (47%) at Schools a and B, respectively. Three major factors were identified: the PT's ability to (1) assess academic learning (2) support clinical learning; (3) the PT's impact on exam preparation. Significant differences were found between settings. In the school with early clinical contact, more frequent PTs and no end of unit tests, students were more likely to appreciate the PT as a support for learning, perceive it as fair and valid, and use a deeper approach to learning-but they also spent longer preparing for the test. CONCLUSION: Different approaches to the delivery of the PT can impact significantly on student study patterns. The learning environment has an important impact on student perceptions of assessment and approach to learning. Careful decisions about PT deployment must be taken to ensure its optimal impact.

BACKGROUND: Map of Medicine is a web-based knowledge resource depicting evidence-based pathways of patient care. Recent publications suggest a possible role for the Map of Medicine as a training tool in postgraduate education. AIM: the aim of this study was to explore the potential of the Map of Medicine to enhance undergraduate medical education. METHODS: a mixed-method study including a survey of UK medical schools, and the embedding of the resource at one medical school and the evaluation of its impact. RESULTS: the survey found that only 1 of 23 medical schools was using the Map of Medicine in its undergraduate curriculum. The Peninsula Medical School students' reaction to the resource was extremely positive. Students liked the Map of Medicine's navigability and help in accessing reliable information. Use of the resource by students grew steadily throughout the period of the study and peaked at 595 sessions a month. There was evidence that usage was directly linked to curricular events, particularly problem-based learning tutorials and medical knowledge assessments. CONCLUSION: There is clear potential for the Map of Medicine in undergraduate medical education and a short-active period of resource promotion led to its embedding within routine learning practice.

OBJECTIVES: Map of Medicine is an evidence-based online clinical knowledge resource. Procured at significant cost by healthcare providers in the UK, Sweden and Denmark, it is important to establish the beneficial impact that investment has had on healthcare practise and, ultimately, on patient outcomes. The objective of this study is to review the evidence for the impact of the Map of Medicine on clinical practice. METHODS: a systematic review of peer-reviewed and grey literature was conducted. Nine healthcare databases, Google Scholar and Google were searched for articles containing the terms 'map of medicine'. RESULTS: the search identified 133 articles. Eleven of the articles identified met the inclusion criteria. The main finding of the study is the paucity of evidence available on the impact of the Map of Medicine and the variable quality of that which does exist. There are some encouraging early indications for the Map of Medicine as a tool within service redesign, leading to an increase in appropriate referrals to secondary care, decreased patient waiting times and considerable cost savings. CONCLUSION: Further research with study designs that can generate high quality evidence for the impact of Map of Medicine is essential in order to support policy decisions.

Developments in clinical education have recently challenged the identity of anatomy teaching and learning, leading to high profile debate over the potential implications for the competence levels of new doctors. However, the emphasis remains on methods of teaching, rather than a review of what well-rounded anatomical learning actually entails, and how teaching can address contemporary learning needs. This paper identifies and addresses some of these issues, drawing on expert views captured in qualitative research with anatomy tutors at twenty different medical schools in the UK. Three main themes emerging from our analysis are described: anatomy as a subject matter, the challenges of teaching or learning anatomy, and the use of teaching methods. We also detail how inductive analysis generated new hypotheses worthy of further consideration. These fall into two key categories: (1) improving anatomy curriculum design and (2) advancing anatomy education research.

Video-linked lectures allow healthcare students across multiple sites, and between university and hospital bases, to come together for the purposes of shared teaching. Recording and streaming video-linked lectures allows students to view them at a later date and provides an additional resource to support student learning. As part of a UK Higher Education Academy-funded Pathfinder project, this study explored medical students' perceptions of video-linked lectures and video-streaming, and their impact on learning. The methodology involved semi-structured interviews with 20 undergraduate medical students across four sites and five year groups. Several key themes emerged from the analysis. Students generally preferred live lectures at the home site and saw interaction between sites as a major challenge. Students reported that their attendance at live lectures was not affected by the availability of streamed lectures and tended to be influenced more by the topic and speaker than the technical arrangements. These findings will inform other educators interested in employing similar video technologies in their teaching. © 2010 Association for Learning Technology.

This review aimed to determine the availability of core curricula for the biomedical sciences in the published literature and the approach taken to determining learning objectives. A systematic review was conducted searching three databases for articles containing the terms 'core curriculum', 'undergraduate' and 'medic*'. Fifty seven papers were read in full, of which 40 listed learning objectives. The authors used a consensus process to categorize the learning objectives according to the level of detail (high / medium / low) and the approach taken (either a top down approach using experts or a bottom up approach using key stakeholders). This paper directs the reader to publications that describe core curricula for the biomedical sciences. The review revealed that topic coverage was patchy and there was a variable level of detail of learning outcomes presented. Documents published by professional bodies tended to provide more detailed learning outcomes than those derived by experts associated with medical schools. Two thirds of the 40 publications used a top down approach and there was a temporal trend towards involving non-expert groups in some stage of the process of defining the learning objectives, regardless of whether a top down or bottom up approach was taken.

Having performed research using approaches to learning and studying inventories and become familiar with the concepts they purport to measure, the authors were concerned that existing inventories might not capture the full range of intentions and motivations for learning that exist within populations of medical students. We used semi-structured interviews to explore the approaches to learning of undergraduate medical students at two time points: in the academic setting (year 2) and subsequently in the clinical setting (year 3). A thematic index was created using a framework analysis approach with the data derived from the academic setting and subsequently applied to and developed by the data derived from the clinical setting. Some themes and sub-themes emerging from the analysis fitted well with the deep, surface and strategic approaches described previously in higher education. Others did not. In particular, the importance of the vocational and social aspects of learning was striking in this sample of students, in both academic and clinical settings, and these would be missed by the majority of existing inventories. This study confirms that existing conceptions of approaches to learning within the higher education literature do not account for the full range of intentions and motivations that exist within medical student populations.

OBJECTIVE: This study sought to determine the relative contributions made by transferable skills and content-specific skills to Year 2 medical student performance in a clinical skills examination. METHODS: Correlated trait-correlated method models were constructed to describe the performance of 2 year groups of students in examinations held in the summers of 2004 and 2005 at Peninsula Medical School in the UK. The transferable skills components of the models were then removed to indicate the contribution made to the fit of the models to the data. RESULTS: Although content-specific skills made the greater contribution to the 2 models of student performance (accounting for averages of 54% and 43% of the variance, respectively), transferable skills did make an important but smaller contribution (averages of 13% and 16%, respectively). When the transferable skills components of the models were removed, the fit was not as good. CONCLUSIONS: Both content-specific skills and transferable skills contributed to performance in the clinical skills examination. This challenges current thinking and has important implications, not just for those involved in clinical skills examinations, but for all medical educators.

AIMS: the aim of the study was to investigate how stresses like low pH, which may be encountered in farms or food preparation premises, shape populations of Salmonella enterica by the selection of stress-resistant variants. METHODS AND RESULTS: Stationary-phase cultures of S. enterica serovar Enteritidis and serovar Typhimurium (one strain of each) were exposed to pH 2.5 for up to 4 h, followed by growth at pH 7 for 48 h. This process was repeated 15 times in two separate experiments, which increased the acid resistance of the three out of four populations we obtained, by three- to fourfold. Sustainable variants derived from the populations showed changes in colony morphology, expression of SEF17 fimbriae, growth, increased heat resistance and reduced virulence. CONCLUSIONS: the study demonstrates that low pH environments can select for populations of S. enterica with persistent phenotypic changes such as increased acid resistance and occasionally increased SEF17 expression and lower virulence. SIGNIFICANCE AND IMPACT OF THE STUDY: There is a common belief that increased acid resistance coincides with increased virulence. This study demonstrates for the first time that increased acid resistance often impairs virulence and affects the general phenotype of S. enterica.

CONTEXT: High-quality learning in the context of medical education can be defined by current conceptions of a deep approach to learning and studying, in combination with metacognitive skills such as personal organisation and reflection on learning. Modern undergraduate education aims to provide an environment that will promote high-quality learning, but this is not as easy to achieve as it might at first seem. Part of the difficulty arises because it is student perceptions of the learning and assessment environment that determine the adopted approach to studying and these are notoriously hard to predict. OBJECTIVE: to generate a detailed understanding of aspects that facilitate and inhibit high-quality learning within an innovative, undergraduate medical programme. METHODS: We carried out semi-structured interviews with Year 2 undergraduate students. RESULTS: Self-directed, problem-based and vocationally relevant activities appeared to promote high-quality learning. Unanticipated barriers to high-quality learning in this setting included a perceived lack of useful feedback on learning, the assessment of applied medical knowledge for a subset of underperforming students, anatomy as a curricular topic and the quantity of information to be assimilated in medicine. CONCLUSIONS: Only by understanding the barriers as they are perceived by students can we design evidence-based modifications to curricula that are likely to be successful in promoting high-quality learning.

The General Medical Council in the UK recommends that undergraduate medical students be exposed to a variety of learning opportunities and increasingly take responsibility for their own learning. This study presents quantitative and qualitative data relating to attendance at non-compulsory plenary lectures in order to understand factors affecting the value placed by students on this component of the first 2 years of a contemporary medical curriculum. Attendance data were available for 87% first year and 78% second year plenary lectures. There was no difference in attendance at lectures that were delivered telematically to a remote site when compared with those where the speaker was present. There were markedly more students attending lectures at the beginning of the first academic year, with numbers decreasing as the year progressed. More first year students attended lectures on biomedical science and clinically focussed topics than on human science and public health whereas second year student attendance was similar across topics. Reasons given for non-attendance at plenary sessions fell into "student-related" factors (e.g. dislike of lecture-based learning) and "teaching-related" factors (e.g. perceived variable quality of lectures). This study confirms that some students value lectures highly as a method to supplement other learning opportunities, whereas others find they learn better by other means.

OBJECTIVES: This research aims to identify the influences contributing to students' decisions to study medicine and to apply the findings to the design and targeting of outreach activities aimed at widening participation. METHODS: Semi-structured interviews were carried out with 15 medical students at a UK medical school. Framework analysis was used to identify themes and subthemes and findings relating to becoming a doctor were analysed further in the context of a theory of career decision making. RESULTS: Five themes and subthemes were identified. We report the results for the 3 main aspects relating to becoming a doctor from the theme School to Medical School Transition: early motivation; inhibitory factors, and facilitating factors. Many students spoke about having always wanted to study medicine. Early exposure to the possibility of being a doctor allowed the idea to flourish and motivated students to achieve high academic goals. Inhibitory factors included discouragement from application by teachers on the grounds of not being 'doctor material'. Factors which facilitated access to medicine included the support of family members, particularly mothers, and other close friends, and having positive role models. CONCLUSIONS: Our analysis provides evidence of important factors in career decision making for medicine which can be used to inform widening participation interventions in 3 areas, namely, those of school support, home support and raising aspirations.

Personal beliefs about what knowledge is and how we understand, integrate and apply knowledge (known as personal epistemologies) are entrenched in the process of decision-making. Evidence-based medicine in all its forms brings with it the need for an ever more sophisticated appreciation of individual patients' perspectives and 'scientific' perspectives within the clinical encounter. However, current theoretical perspectives on personal epistemology focus more on scientific ways of knowing where knowledge is abstracted and logical. We conducted semi-structured interviews to investigate medical students' personal epistemological thinking towards the end of their second year of training at a new medical school in the South West of England. Whilst responses were varied, students appeared to express predominantly simplistic levels of epistemological thinking according to current developmental models of personal epistemology. However, the process of professional identity formation together with epistemological thinking brought together both scientific and experiential ways of knowing in a way that has largely been ignored by current theorists in the domain of personal epistemology.

OBJECTIVES: to characterise UK undergraduate medical ethics curricula and to identify opportunities and threats to teaching and learning. DESIGN: Postal questionnaire survey of UK medical schools enquiring about teaching and assessment, including future perspectives. PARTICIPANTS: the lead for teaching and learning at each medical school was invited to complete a questionnaire. RESULTS: Completed responses were received from 22/28 schools (79%). Seventeen respondents deemed their aims for ethics teaching to be successful. Twenty felt ethics should be learnt throughout the course and 13 said ethics teaching and learning should be fully integrated horizontally. Twenty felt variety in assessment was important and three tools was the preferred number. A shortfall in ethics core competencies did not preclude graduation in 15 schools. The most successful aspects of courses were perceived to be their integrated nature and the small group teaching; weaknesses were described as a need for still greater integration and the heavily theoretical aspects of ethics. The major concerns about how ethics would be taught in the future related to staffing and staff development. CONCLUSIONS: This study describes how ethics was taught and assessed in 2004. The findings show that, although ethics now has an accepted place in the curriculum, more can be done to ensure that the recommended content is taught and assessed optimally.

OBJECTIVE: to determine whether the recommendations of the Consensus Statement published 7 years ago have been implemented. DESIGN: Postal questionnaire survey of 28 UK medical schools. METHODS: a survey was sent to the lead individual for teaching and learning at each medical school. This questionnaire inquired about the undergraduate ethics and law curriculum, including its design, teaching, assessment, staffing, and individuals' hopes and concerns for the future. MAIN OUTCOME MEASURES: Information relating to undergraduate ethics teaching in UK medical schools. RESULTS: Significant changes in the teaching and assessment of medical ethics and law that could be directly attributed to the Consensus Statement were identified. Whilst most schools covered all 12 recommended topics in their curriculum, only 3 felt all the topics were covered thoroughly and 3 schools said at least 1 topic was not covered at all. Only 16 schools identified 1 or more full-time academics who took direct responsibility for ensuring undergraduate medical students learnt about ethics; these were usually at lecturer grade. CONCLUSIONS: the Consensus Statement has had a significant impact on the teaching of undergraduate ethics but, even 7 years on, not all its recommendations have been implemented fully.

Research into interprofessional education is often performed by professionals in practice alongside their other "core" duties, thus additional help and support to achieve quality research outcomes would be beneficial. This study aimed to create a virtual community of researchers with shared interest in quantitative studies of interprofessional learning using the Readiness for Interprofessional Learning Scale. An e-resource was built which provided access to relevant resources, helped to coordinate research effort, and promoted communication. Use of the resource was monitored over a 14-month period and evaluated at the end of this time. Forty-eight researchers across six different countries were assigned usernames and passwords. According to a self-report measure, 23/27 (85%) respondents to the evaluation questionnaire had accessed the resource and 95% planned to use it in the coming year. This paper shares our experiences and observations from the study.

INTRODUCTION: Inventories to quantify approaches to studying try to determine how students approach academic tasks. Medical curricula usually aim to promote a deep approach to studying, which is associated with academic success and which may predict desirable traits postqualification. AIMS: This study aimed to validate a revised Approaches to Learning and Studying Inventory (ALSI) in medical students and to explore its relation to student characteristics and performance. METHODS: Confirmatory factor analysis was used to validate the reported constructs in a sample of 128 Year 1 medical students. Models were developed to investigate the effect of age, graduate status and gender, and the relationships between approaches to studying and assessment outcomes. RESULTS: the ALSI performed as anticipated in this population, thus validating its use in our sample, but a 4-factor solution had a better fit than the reported 5-factor one. Medical students scored highly on deep approach compared with other students in higher education. Graduate status and gender had significant effects on approach to studying and a deep approach was associated with higher academic scores. CONCLUSIONS: the ALSI is valid for use in medical students and can uncover interesting relationships between approaches to studying and student characteristics. In addition, the ALSI has potential as a tool to predict student success, both academically and beyond qualification.

AIM: There are few publications summarising the main issues concerning pathology teaching and learning within undergraduate medical degrees. This article examines the themes that have emerged from the literature over the last 2 decades. METHOD: a literature search was performed using PubMed, which identified 86 relevant papers in the English language. RESULTS: the themes discussed in the literature included the timing and duration of pathology courses, the appropriate pathology teacher for medical students, the teaching strategies used for pathology, and the methods used to assess learning. DISCUSSION: with the gradual increase of integrated medical curricula, it is important for pathology teachers to engage in the change process and help to shape the new-style courses. One of the positive aspects of change is that it can provide an opportunity to rethink current practice. It is hoped that this paper might stimulate discussion about how pathology is taught and learnt, leading to further developments in this area.

The development of a hot water treatment to reduce bacterial numbers on poultry carcasses is described. Initial trials identified suitable time/temperature for hot water immersion treatments and in subsequent work an experimental in-line processing unit was constructed and evaluated. Microbiological testing for organisms that are indicators for potential food spoilage (aerobic plate count) and human disease (Enterobacteriaceae, Campylobacter) was performed to assess the benefit of the treatment. A treatment of 75 °C for 30 s significantly reduced the numbers of bacteria but the chicken skin tended to tear as the legs and wings were moved into position for a neat pack appearance (trussing). A treatment of 70 °C for 40 s, however, did not detrimentally affect the chicken skin. In addition, aerobic plate, Enterobacteriaceae and Campylobacter counts for treated samples were significantly lower than the controls (P = 0.005) for 8 days under typical chilled storage conditions. © 2003 Elsevier Ltd. All rights reserved.

Changes are occurring in undergraduate medical curricula and there is limited published information about how contemporary tissue pathology is taught. The aim of this study was to collect information on this topic and to invite expert opinion about best teaching practice. A postal questionnaire survey of medical schools in the UK was performed, with a response rate of 23/28 schools (82%). The two most striking findings were the variation in teaching and learning strategies between schools and the spirit of the respondents, some relishing the challenges associated with reorganization and some thoroughly demoralized. The main concerns about pathology teaching were a feeling of lack of ownership of the content taught, an overall lack of visibility of tissue pathology in teaching and assessment, and staff shortages. Respondents valued the autopsy as an educational tool but were finding it increasingly difficult to provide. On the other hand, key opportunities for pathology teaching were highlighted through the questionnaire. The potential for developments in information technology and the possibility of creating national forums to develop core curricula and generate e-resources was recognized. The findings of this study will provide a milestone against which future change in pathology education can be measured.

In this study, the formation of multicellular filamentous Salmonella cells in response to low temperatures was investigated by using isolates of Salmonella enterica serovar Enteritidis PT4 and S. enterica serovar Typhimurium DT104 as the inocula. The formation of filamentous cells in two liquid food matrices at the recommended maximum temperature for refrigeration (8 degrees C) was monitored and compared with that in tryptone soya broth. Giemsa staining was performed to locate nuclear material within the filaments. Single filaments were warmed on agar at 37 degrees C, and the subsequent rate of septation was quantified. For all strains tested, > 70% of the Salmonella cells inoculated had become filamentous after 4 days in media at 8 degrees C, indicating that filamentation could occur during the shelf life of most refrigerated foods. Strains with impaired RpoS expression were able to form filaments at 8 degrees C, although these filaments tended to be shorter and less numerous. All strains also formed filamentous cells at 8 degrees C in retail milk or chicken meat extract. Filaments often exceeded 100 microm in length and appeared straight-sided under the microscope in media and in foods, and Giemsa staining demonstrated that regularly spaced nucleoids were present. This phenotype indicates that an early block in cell septation is probably responsible for filamentation. When filaments were warmed on agar at 37 degrees C, there was a rapid completion of septation, and for one filament, a >200-fold increase in cell number was observed within 4 h. There are clear public health implications associated with the filamentation of Salmonella in contaminated foods at refrigeration temperatures, especially when the possibility of rapid septation of filamentous cells upon warming is considered.

AIMS: There is a belief that interprofessional learning among health care professionals promotes teamwork and collaboration, leading to improved patient care, but supporting data have not been available. Our aim was to identify recent studies on interprofessional learning involving medical students or doctors. METHODS: the medical education literature was searched for relevant publications since 1998 and the studies were subsequently classified according to various criteria. RESULTS: a total of 24 'research papers' and 36 'literature review/editorial-type papers' were identified. Research papers generally described interprofessional learning initiatives and evaluated their success in terms of knowledge or attitudes by data collection. Seven collected qualitative data, 4 collected quantitative data and 11 collected both. None of the studies identified conformed to the Cochrane Collaboration guidelines for a rigorous source of quantitative information on an intervention's effectiveness. DISCUSSION: the authors suspect that significantly more studies have been performed than those published. This may indicate research of variable quality, leading to a large proportion of papers being rejected for publication. More and better quality research is required as more resources become available to academic and health care organisations for interprofessional learning.

Certain rod-shaped bacteria have been reported to form elongated filamentous cells when exposed to marginal growth conditions, including refrigeration temperatures. To expand upon these observations, the filamentation of commensal Escherichia coli, E. coli O157:H7 and Salmonella spp was investigated, following exposure to certain, mildly stressing, levels of temperature, pH or water activity (aw), with levels of cellular protein being monitored during cell elongation, in some experiments. Our studies indicated that cellular filamentation could be demonstrated in all 15 strains of the above organisms tested, following exposure to marginal conditions achieved by incubation at high or low temperatures, high or low pH values and low aw. The level of environmental stress causing filamentation tended to be specific to the particular organisms. For example, Salmonella spp formed filamentous cells at 44 degrees C, whereas E. coli strains, including O157, grew by binary fission at that temperature, but formed filamentous cells at 46 degrees C. In addition, plate count techniques to enumerate bacteria during filamentation, failed to reflect the increase in cell biomass that was occurring, whereas measurements of protein concentration demonstrated the increase quite strikingly. These findings have important implications for our understanding of the ability of food-borne pathogens to cause disease, since the infectious dose of a microorganism implicated in an outbreak of such disease is typically determined by a viable count method, which could underestimate the number of potential infectious units present in a food that had been stored in such a way as to provide marginal growth conditions.

AIMS: to determine the microbiological quality of washing-up water and the environment in domestic and commercial kitchens. METHODS AND RESULTS: Chicken meals were prepared by people without food safety training in their own kitchen (n = 52) or by trained staff in a commercial kitchen (n = 10). Study participants then washed-up, cleaned the kitchen and completed a food hygiene questionnaire. The temperature and microbiological quality of the washing-up water, and the presence of pathogens in dishcloths, tea towels and other kitchen samples was determined. of the raw chickens used in meal preparation, 96 and 13% were naturally contaminated with Campylobacter or Salmonella spp. respectively. In domestic kitchens, two of 45 sponges, dishcloths or scourers and one of 32 hand- or tea towels were contaminated with Campylobacter after washing-up and cleaning but none of the tap or sink swabs yielded pathogens. The mean washing-up water temperature in the domestic kitchens was 40.7 degrees C, whereas in the commercial kitchen it was 44.7 degrees C (P = 0.04). Study participants who used hotter water (>/=40 degrees C) had lower levels of bacteria in their washing-up water. The aerobic plate counts of the washing-up water samples in domestic homes were usually between 105 and 106 CFU ml-1 but those associated with the commercial kitchen were consistently lower (P = 0.01). Despite this, Campylobacter was detected in one of 10 washing-up water samples from the commercial kitchen but in none of the samples from domestic kitchens. CONCLUSIONS: Pathogenic microorganisms can be recovered relatively frequently from the kitchen environment. SIGNIFICANCE AND IMPACT OF STUDY: By identifying factors that affect the number of microorganisms in washing-up water and the kitchen environment, evidence-based recommendations on implementing domestic food hygiene can be made.

In this study, the survival of Salmonella, Campylobacter and Escherichia coli O157: H7, when exposed to a range of constant temperatures (47-60 degrees C), in hard or soft water, in the presence/absence of detergent (0-0.3%) and organic matter, and during drying, was investigated. Further experiments used a washing-up process simulation, where soiled dishes contaminated with bacteria were washed in a bowl of warm water containing detergent. In addition, this study considered the risk of bacterial transfer onto (1) sterile dishes and sponges via contaminated water, (2) kitchen surfaces wiped with a contaminated sponge, (3) items placed in direct contact with a contaminated kitchen surface, (4) food placed on a contaminated dish or (5) dishes from contaminated food. A proportion of dishes remained contaminated with all pathogen types after a typical washing-up. Water hardness did not appear to affect survival. E. coli, and to a lesser extent Salmonella, survived towel- or air-drying on dishes and after towel-drying the cloth became contaminated on every occasion, regardless of the test organism. A proportion of sterile dishes washed after contaminated dishes became contaminated with pathogens but transfer from dishes onto food was rare. Washing-up sponges frequently became contaminated with pathogens. The results of this study highlight the potential for survival and cross contamination of food borne pathogens in the kitchen environment.

AIMS: Laboratory media for the isolation of Campylobacter usually contain various selective agents, designed to allow these bacteria to grow whilst suppressing that of other organisms. For example, cycloheximide has often been incorporated into Campylobacter media to inhibit the growth of fungi. The production and availability of cycloheximide, however, has recently decreased due to concerns relating to its potential toxicity for mammalian cells and the compound has also become more expensive as a result. An alternative antifungal agent is necessary, and to address this, the effect of using amphotericin B in place of cycloheximide in Campylobacter selective broths and agars was examined. METHODS AND RESULTS: the growth of Campylobacter strains and the suppression of potential competitor organisms in selective broths or on selective agars containing either amphotericin B or cycloheximide was quantified, using pure microbial cultures. The results were then confirmed by testing food and water samples that contained high levels of micro-organisms, including Campylobacter. CONCLUSIONS: the results of this study indicate that amphotericin B is a suitable replacement for cycloheximide in Campylobacter selective media.

AIMS: to determine the prevalence and number of Salmonella and Campylobacter in sausages and to evaluate their destruction during cooking. METHODS AND RESULTS: One hundred and sixty-two packs of uncooked economy or catering sausages, comprising 53 packs of frozen and 109 of chilled sausages, were purchased in Devon between March and July 2000. All were tested for the presence of Salmonella and 51 packs of chilled sausages were also examined for the presence of Campylobacter spp. To investigate the heat tolerance of Salmonella enterica serovar Typhimurium DT104 in sausage-meat, chilled, handmade and frozen sausages were inoculated with approx. 1.5 x 10(4) bacterial cells per sausage (approximately 300 cfu g(-1)) and then cooked by frying, grilling or barbecuing. The levels of creatinine kinase, lactate dehydrogenase and alkaline phosphatase in uncooked and cooked sausages were measured to evaluate their potential as indicators of adequate cooking and, therefore, pathogen elimination. Salmonella were detected in 7.5% of frozen and 9.1% of the chilled sausages (8.6% overall) but Campylobacter spp. were not isolated. After cooking, a visual assessment suggested that all of the sausages were thoroughly cooked. Despite this, barbecuing and frying sometimes allowed Salmonella cells to survive and the temperature profiles during cooking indicated that the lethal range was sometimes not reached. The enzyme levels tested were not reliable indicators of the inactivation of bacterial pathogens because Salmonella were sometimes isolated from sausages with low values of all three enzymes. CONCLUSIONS: Salmonella spp. are present in a significant proportion of sausages and are not always killed during the cooking process. SIGNIFICANCE AND IMPACT OF THE STUDY: These findings have clear implications for public health.

Salmonella cells in two sugar-rich media were heat treated at various constant temperatures in the range of 55 to 80 degrees C and their survival ratios determined at various time intervals. The resulting nonlinear semilogarithmic survival curves are described by the model log10S(t) = -b(T)tn(T), where S(t) is the momentary survival ratio N(t)/N0, and b(T) and n(T) are coefficients whose temperature dependence is described by two empirical mathematical models. When the temperature profile, T(t), of a nonisothermal heat treatment can also be expressed algebraically, b(T) and n(T) can be transformed into a function of time, i.e. b[T(t)] and n[T(t)]. If the momentary inactivation rate primarily depends on the momentary temperature and survival ratio, then the survival curve under nonisothermal conditions can be constructed by solving a differential equation, previously suggested by Peleg and Penchina, whose coefficients are expressions that contain the corresponding b[T(t)] and n[T(t)] terms. The applicability of the model and its underlying assumptions was tested with a series of eight experiments in which the Salmonella cells, in the same media, were heated at various rates to selected temperatures in the range of 65 to 80 degres C and then cooled. In all the experiments, there was an agreement between the predicted and observed survival curves. This suggests that, at least in the case of Salmonella in the tested media, survival during nonisothermal inactivation can be estimated without assuming any mortality kinetics.

Salmonella spp. are reported to have an increased heat tolerance at low water activity (a(w); measured by relative vapor pressure [rvp]), achieved either by drying or by incorporating solutes. Much of the published data, however, cover only a narrow treatment range and have been analyzed by assuming first-order death kinetics. In this study, the death of Salmonella enterica serovar Typhimurium DT104 when exposed to 54 combinations of temperature (55 to 80 degrees C) and a(w) (rvp 0.65 to 0.90, reduced using glucose-fructose) was investigated. The Weibull model (LogS = -bt(n)) was used to describe microbial inactivation, and surface response models were developed to predict death rates for serovar Typhimurium at all points within the design surface. The models were evaluated with data generated by using six different Salmonella strains in place of serovar Typhimurium DT104 strain 30, two different solutes in place of glucose-fructose to reduce a(w), or six low-a(w) foods artificially contaminated with Salmonella in place of the sugar broths. The data demonstrate that, at temperatures of > or =70 degrees C, Salmonella cells at low a(w) were more heat tolerant than those at a higher a(w) but below 65 degrees C the reverse was true. The same patterns were generated when sucrose (rvp 0.80 compared with 0.90) or NaCl (0.75 compared with 0.90) was used to reduce a(w), but the extent of the protection afforded varied with solute type. The predictions of thermal death rates in the low-a(w) foods were usually fail-safe, but the few exceptions highlight the importance of validating models with specific foods that may have additional factors affecting survival.

This study describes the evaluation of potentially more sensitive methods for the recovery of Salmonella cells injured by heating (54 to 60 degrees C) at different water activity values (0.65 to 0.90, reduced using equal portions of glucose and fructose). These methods included gradual rehydration, the use of diluting media with added solutes or blood, the addition of blood to plating agar, and the use of different incubation temperatures and times. Gradual rehydration of cells that had been challenged at low water activity (0.65 and 0.70) and high temperature markedly improved recovery, measured as a >50% increase in the time to obtain a 3-log10 reduction in cell numbers, compared to dilution into media with a high water activity. Adding sucrose, glycerol, or blood to the diluting media (maximal recovery diluent) did not improve recovery, but a plating agar containing blood recovered approximately 38% more cells than nutrient agar. Prolonged incubation of agar plates allowed recovery of injured Salmonella cells that presumably had extended lag periods, with significantly higher recovery rates after 48 h incubation at 37 degrees C than after 24 h (P = 0.05). This work highlights that by recovering Salmonella using a method specific to the nature of the injury, a better prediction of food safety and the success of food processing can be made.

Norwalk-like viruses (NLV) are important economically as a cause of both sporadic gastroenteritis in the community and large outbreaks in hospitals and other institutional settings. Despite the description of several antigenic types relatively little is known about the epidemiology of these individual types. NLVs were detected by electron microscopy in faecal specimens from 706 outbreaks of gastroenteritis that represented 68% of all outbreaks of non-bacterial gastroenteritis. These outbreaks took place in the counties of West and North Yorkshire and Humberside during six winter seasons between July 1992 and June 1998. NLV strains from 671 outbreaks were typed by antigen capture enzyme linked immunosorbent assays (ELISA) based on antisera made to recombinant virus-like particles of three antigenically distinct NLVs; Norwalk (NV), Mexico (MXV) and Grimsby (GRV) viruses. GRV was the predominant strain for five of the six winter seasons and overall was associated with 61% of NLV outbreaks. MXV was responsible for a single epidemic peak in the winter of 1993/94 but was also observed at other times throughout the study period. NV was only associated with two outbreaks in 1994 that were epidemiologically linked. Strains from the remaining 32% of outbreaks were non-reactive in all three ELISA. Thus, a single NLV antigenic type seems to have predominated during the period 1992 to 1998 in the UK.

The effect of habituation at reduced water activity (a(w)) on heat tolerance of Salmonella spp. was investigated. Stationary-phase cells were exposed to a(w) 0.95 in broths containing glucose-fructose, sodium chloride, or glycerol at 21 degrees C for up to a week prior to heat challenge at 54 degrees C. In addition, the effects of different a(w)s and heat challenge temperatures were investigated. Habituation at a(w) 0.95 resulted in increased heat tolerance at 54 degrees C with all solutes tested. The extent of the increase and the optimal habituation time depended on the solute used. Exposure to broths containing glucose-fructose (a(w) 0.95) for 12 h resulted in maximal heat tolerance, with more than a fourfold increase in D(54) values. Cells held for more than 72 h in these conditions, however, became as heat sensitive as nonhabituated populations. Habituation in the presence of sodium chloride or glycerol gave rise to less pronounced but still significant increases in heat tolerance at 54 degrees C, and a shorter incubation time was required to maximize tolerance. The increase in heat tolerance following habituation in broths containing glucose-fructose (a(w) 0.95) was RpoS independent. The presence of chloramphenicol or rifampin during habituation and inactivation did not affect the extent of heat tolerance achieved, suggesting that de novo protein synthesis was probably not necessary. These data highlight the importance of cell prehistory prior to heat inactivation and may have implications for food manufacturers using low-a(w) ingredients.

TT-virus (TTV, patient initials: T.T.), a novel DNA virus, was first isolated in Japan in 1997 from serum of a patient with post-transfusion hepatitis of unknown aetiology. To date, the contribution of TTV to liver disease remains doubtful. The potential for transmission via blood and blood products makes it essential to establish the prevalence of TTV viraemia in the blood donor population. 413 blood donor serum samples were chosen randomly, the DNA was extracted and TTV-specific DNA amplified by nested polymerase chain reaction (PCR). TTV infection was present in 13 out of 413 (3.15%) blood donors in the Auckland region of New Zealand using a set of primers targeting open reading frame (ORF) 1. These 13 amplification products (264 bp) were sequenced and TTV genotypes determined. Alignment with published TTV sequences showed that seven (53.8%) of the thirteen positive serum samples belonged to genotype 1, five (38.5%) belonged to genotype 2 and one (7.7%) could not be classified as either genotype 1 or 2. One hundred twenty-seven blood donor serum samples were retested with a second set of primers targeting the 5' region of the TTV genome in a single round PCR. Forty-three samples were positive for TTV DNA with these primers resulting in a prevalence of 37%. The data demonstrate that TTV is present among New Zealand blood donors and support the need for further investigation into the natural history of TTV infection. (C) 2000 Wiley-Liss, Inc.

In this study we investigated the long-term survival of and morphological changes in Salmonella strains at low water activity (a(w)). Salmonella enterica serovar Enteritidis PT4 and Salmonella enterica serovar Typhimurium DT104 survived at low a(w) for long periods, but minimum humectant concentrations of 8% NaCl (a(w), 0. 95), 96% sucrose (a(w), 0.94), and 32% glycerol (a(w), 0.92) were bactericidal under most conditions. Salmonella rpoS mutants were usually more sensitive to bactericidal levels of NaCl, sucrose, and glycerol. At a lethal a(w), incubation at 37 degrees C resulted in more rapid loss of viability than incubation at 21 degrees C. At a(w) values of 0.93 to 0.98, strains of S. enterica serovar Enteritidis and S. enterica serovar Typhimurium formed filaments, some of which were at least 200 microm long. Filamentation was independent of rpoS expression. When the preparations were returned to high-a(w) conditions, the filaments formed septa, and division was complete within approximately 2 to 3 h. The variable survival of Salmonella strains at low a(w) highlights the importance of strain choice when researchers produce modelling data to simulate worst-case scenarios or conduct risk assessments based on laboratory data. The continued increase in Salmonella biomass at low a(w) (without a concomitant increase in microbial count) would not have been detected by traditional microbiological enumeration tests if the tests had been performed immediately after low-a(w) storage. If Salmonella strains form filaments in food products that have low a(w) values (0.92 to 0.98), there are significant implications for public health and for designing methods for microbiological monitoring.

Molecular epidemiological studies of Norwalk-like viruses (NLVs), previously known as small round structured viruses (SRSVs), are dependant currently on DNA sequencing of PCR amplicons, which is expensive and time consuming. The Heteroduplex Mobility assay (HMA) was evaluated as a method for identification of PCR amplicons from the commonly circulating NLV strains without DNA sequencing. The procedure was developed for use with two reference strains, a Mexico virus-like strain (MXV-like; Hu¿NLV¿RBH¿1993¿UK) and the Grimsby virus strain (Hu¿NLV¿Gimsby¿1995¿UK), and was optimised with regards to the annealing and electrophoresis conditions and the electrophoresis gel matrix. Using the optimised conditions, amplicons of less than 90% sequence identity formed visible heteroduplexes, allowing the strains to be placed into three categories; Mexico-like, Grimsby-like and non-Mexico virus/non-Grimsby virus strains. Outbreak strains 'genotyped' previously by DNA sequencing as Mexico virus or Grimsby virus were identified correctly by the heteroduplex mobility assay. The procedure was applied prospectively to strains from 130 outbreaks occurring in the UK between 1997 and 1998. Heteroduplex mobility assay was successful on 120 (92%) strains of which 68 (57%) were GRV-like strains, three (2.5%) were Mexico virus-like strains and 49 (41%) were categorised as non- Mexico/non-Grimsby virus strains. Amplicons from 50 of the 120 strains were sequenced and there was perfect correlation between the heteroduplex mobility assay categorisation and phylogenetic analysis. HMA offers a rapid, robust and far cheaper alternative to sequencing for the identification of prevalent Norwalk-like virus genotypes for molecular epidemiological studies.

Aeromonas spp. are detected in more than 500 cases of gastrointestinal infection each year in England and Wales. This study aimed to identify their prevalence in ready-to-eat salads, which are a potential source of aeromonas infection. The protocol for isolation of mesophilic Aeromonas spp. from salads was optimised. Using the improved method, Aeromonas spp were isolated from 19 of 25 samples (25 g) of ready-to-eat salad products. Aeromonas organisms were counted, isolates were identified to species level, and the effect of pH on colonisation of salads was assessed. Aeromonas was present at high levels in six salads (> or = 100 cfu/g). The major species present in salads was Aeromonas caviae, but A.hydrophila and A.sobria, which have more pathogenic potential, were also isolated. It is hoped that this study will help to assess the risk to public health of aeromonas in salads.

Mesophilic Aeromonas spp. are isolated regularly from cases of gastrointestinal infection and have markers indicative of enteropathogenicity. Is aeromonas, which is present in a large proportion of ready-to-eat salads, actually a gastrointestinal pathogen? Isolates of mesophilic aeromonas from salads were characterised in terms of their ability to grow at refrigeration temperatures over the given shelf life and by the presence of markers of potential virulence. The major phenospecies present in salads, A.caviae, showed little enteropathogenic potential. Thirty-five per cent of aeromonas salad isolates are A.hydrophila or A.sobria, however, and all isolates tested had at least one marker of enteropathogenicity, including cytotoxin and haemolysin production, adherence to epithelial cells, and resistance to certain antibiotics Despite the presence of markers of enteropathogencity, the lack of epidemiological evidence of a link between infectious intestinal disease and the consumption of salads suggests that their contamination with aeromonas does not pose a significant risk to health in immunocompetent adults.