Student assistantship
A prolonged assistantship for final-year students Elewys Lightman1*, Sarah Kingdon2* and Michael Nelson3 1
Department of Clinical Genetics, Northwick Park Hospital, London, UK Oncology Department, The Royal London Hospital, London, UK 3 Department of Medical Education, Sheffield Teaching Hospitals, Sheffield Medical School, UK 2
SUMMARY Background: The transition from medical student to junior doctor is challenging, therefore adequate preparation during medical school is crucial for a smooth transition. Tomorrow’s Doctors expects students to undertake a student assistantship, separate from the local shadowing period prior to commencing employment. Sheffield Medical School initiated a 6–week assistantship within the Yorkshire and Humber deanery. This mixedmethodology study explores this experience from the perspective of final-year medical students.
Methods: Final-year medical students responded to a questionnaire about anxieties surrounding their forthcoming foundation year 1 (FY1). Students were purposefully sampled and semi-structured interviews (SSIs) were conducted, with 20 participants exploring their experience of the assistantship. Interviews were transcribed verbatim and thematic analysis was carried out. Results: The questionnaire results highlighted that most students felt anxious about becoming a FY1 doctor, and subsequent interviews demonstrate that the assistantship
mostly met with students’ expectations. Major themes regarding their anxieties included the value of building professional relationships, familiarisation with the work environment, level of supervision and the value of targeted teaching. Discussion: Student assistantships clearly improve preparedness and confidence in the transition to FY1 by enabling supervised, stepwise responsibility. In the future a nationally cohesive programme should be created for shadowing and assistantships matched with students’ prospective jobs.
Tomorrow’s Doctors expects students to undertake a student assistantship
*Joint first authorship. © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 115–120 115
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‘Shadowing’ periods do not create ample opportunity to assimilate the required nonclinical competencies
INTRODUCTION The transition from medical student to the first year of practising as a qualified doctor, known as foundation year 1 (FY1) in the UK, is renowned as among the most difficult in a doctor’s career. It has been shown that, following the completion of final exams, graduates feel armed with knowledge yet lack confidence in their practical workplace skills.1 A 2000/2001 survey revealed that 42 per cent of newly qualified doctors in the UK felt unprepared by their medical school for their first clinical posts, leading to stress and negatively impacting on doctors’ wellbeing.2
team. Students were based at one of seven centres in the South Yorkshire Deanery, including four district general hospitals and three tertiary referral centres. This study aimed to explore the perceptions of these students on their preparedness for clinical practice following the assistantship.
METHODS
The General Medical Council recommends that all students in the UK undertake ‘shadowing’ (following a junior doctor at work, but without undertaking any duties) in order to familiarise themselves with the local workplace as near to the time of starting work as possible.3 Provisions have been made for all UK doctors to undertake four mandatory paid ‘shadowing’ days immediately prior to starting work; however, ‘shadowing’ periods do not create ample opportunity to assimilate the required nonclinical competencies.4
A short purpose-designed questionnaire (Appendix S1) was developed and piloted with six medical students, to ensure content and face validity of the questions. Figure 1 outlines the study timeline in relation to the student assistantship. The whole year group were invited to complete the questionnaire on day 1. Students self-assessed their anxieties and expected confidence level after the student assistantship, using a Likert scale (1, not at all confident; 5, very confident). Aspects of the FY1 role were categorised; clerking patients, assessing emergencies ward work, clinical skill, and communicating with patients. Questionnaires were not anonymous as participants indicated whether they were happy to be contacted for interview.
The 2009 Tomorrow’s Doctors guidance also recommends a student assistantship (where a student acts as an assistant to a junior doctor, with defined clinical duties under appropriate supervision) towards the end of the undergraduate course to increase students’ preparedness to practice.5 Sheffield Medical School has introduced a 6–week student assistantship for finalyear medical students immediately following their finals. Students were informed as to whether they had passed their exams, but regardless of their result they undertook the programme. Those staying for employment in the area work with their prospective clinical
Purposeful sampling of 20 students was carried out, including at least one participant from each of the seven hospital sites (Table 1). Students’ responses to the questionnaire were investigated carefully, categorising ‘1 or 2’, ‘3 or 4’ or ‘5’ for each domain as ‘anxious’, ‘moderately anxious’ or ‘confident’, respectively. In accordance with the quantitative data (Figure 2), the majority of students invited for interview had indicated that they were anxious or moderately anxious in one or more of the domains investigated (Table 1). Outliers were also targeted to explore the views of those who were either very confident or very anxious.
The majority of students were assistants at tertiary centres, and 55 per cent (11/20) were shadowing their upcoming job (Table 1). Recruitment took place alongside analysis enabling researchers to identify, test and modify themes, and interviews took place between weeks 3 and 6 of the programme. Interviews were recorded and transcribed verbatim, and thematic analysis was carried out independently by two researchers blind to one other. Themes were cross-checked between researchers and then re-coded according to the agreed refined coding frames. Ethical approval was granted by the University of Sheffield.
RESULTS Questionnaire The response rate was 88 per cent (137/156), and the anxiety values reported for each section of the FY1 role are shown in Figure 2. Assessing emergencies was the area students were most anxious about. The majority of students self-reported feeling moderately anxious about each domain of the FY1 role, and expected to become more confident in every section after the assistantship (Figure 2).
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Interviews The student assistantship was well received, with the majority of students describing a positive experience; however, those moving to other geographical areas for employment felt that they were at a disadvantage (Table 2, theme 1).
Final exams
Results
Student assistantship (6 weeks)
Week 1 Lectures
Weeks 2–6 Ward-based placement
Day 1 Questionnaire
Students described feeling part of the team and having a sense of purpose
Understanding their place within the multidisciplinary team Students described feeling part of the team and having a sense of purpose. They had not experienced this in previous clinical attachments (Table 2, theme 2), where many felt ‘in the way’ and not useful in contributing to patient care. It appears that these students were longing for some responsibility and a clearly defined role in the workplace. Student 3’s comments illustrate the added motivation to work hard and impress future colleagues (Table 2, theme 2).
Weeks 3–6 Interviews: concurrent sampling and analysis
FY1 year
Figure 1. Timeline of the study in relation to the student assistantship
Table 1. Interview participants details Participant
Site*
Shadowing Reason invited to interview out of area (Y, yes; N, no)
Interviewer
Student 1
1
Y
Anxious (assessing emergencies)
EGL
Student 2
2
Y
Moderate anxiety in each domain EGL
Student 3
3
N
Moderate anxiety in each domain SJK
Student 4
3
N
Anxious and high expectations
Student 5
4
Y
Moderate anxiety in each domain EGL
Student 6
5
Y
Anxious (assessing emergencies)
SJK
Student 7
6
Y
Anxious (all domains)
SJK
Student 8
7
Y
Anxious (assessing emergencies)
SJK
Student 9
3
N
Moderate anxiety in each domain EGL
Student 10
5
Y
Moderate anxiety in each domain SJK
Student 11
5
Y
Anxious (ward work)
Student 12
4
N
Moderate anxiety in each domain SJK
Student 13
5
N
Moderate anxiety in each domain EGL
Student 14
3
N
Moderate anxiety in each domain EGL
Student 15
3
N
Anxious (all domains)
EGL
Student 16
3
N
Anxious (all domains)
EGL
Student 17
1
N
Confident in all domains
SJK
Student 18
4
Y
Moderate anxiety in each domain SJK
Student 19
3
N
Confident in all domains
Student 20
1
Y
Moderate anxiety in each domain EGL
SJK
SJK
EGL
*1, 3, 6, tertiary referral centres; 2, 4, 5, 7, district general hospitals.
Learning how the multidisciplinary team approach is used in decision making helped assistants to appreciate shared responsibility, escalation and who was available to help immediately in the care of patients who are unwell. Both assistants moving out of area and staying in area felt reassured by this (Table 2, theme 2). Some students still indicated that they had fears of making mistakes and causing serious harm. Developing ‘first-day competencies’ under close supervision Graduated responsibility over the assistantship period was effective in improving confidence in their own ability by having constant informal feedback on their work (Table 2, Theme 3). Student 6, who had indicated that they were anxious at the beginning of the student assistantship, felt endorsed by passing their finals and ready to actively contribute to patient care (Table 2). In contrast, some became a little frustrated as they were overly supervised and not encouraged to work independently.
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140
120 Confidence raƟng key
100
Number of parƟcipants
Students who were made to feel part of the team and given responsibility for tasks felt more confident and prepared
5 4 80
3 2
60
1
40
20
0 1
2
Before Predicted PSA aŌer PSA
Confidence regarding admiƫng paƟents
3
4
5
Before Predicted PSA aŌer PSA
6
7
8
9
10
Before Predicted PSA aŌer PSA
Confidence regarding Confidence regarding ward work assessing emergencies
11
12
13
14
Before Predicted PSA aŌer PSA
Before Predicted PSA aŌer PSA
Confidence regarding clinical skills
Confidence regarding communicaƟon with paƟents, families and carers
15
16
17
Before Predicted PSA aŌer PSA
Confidence regarding communicaƟon with colleagues
Figure 2. A clustered bar chart exhibiting the questionnaire results. Participants predicted an increase in confidence ratings in all categories after the prolonged student assistantship (PSA). Confidence ratings were scored from 1 to 5 (1, not at all confident; 5, very confident)
Prepared for site-specific clinical competencies Students recognised that the development of generic or nonclinical skills was imperative for their upcoming role, and often felt that this was easier for those working within their future trust (Table 2, theme 4). Those students working in their prospective jobs benefitted from having log-ins for the trust’s clinical computer programs, enabling them to be familiar with how to use them and more independent in checking investigation results. Non ward-based teaching The assistantship included a workbook of common pitfalls in prescribing for students to complete and review with a clinical pharmacist (Table 2, theme 5). This was popular with student assistants, particularly as many had specified prescribing as an area of concern. Some students wanted further prescribing teaching (Table 2, students 4 and 7). Some hospitals offered a simulation day for emergencies, which was well received by the students who had taken part
(Table 2, student 4). Working through an emergency situation in a non-threatening environment went a long way to prepare students for a real-life situation. Students criticised lecture-based teaching, particularly if the subject was repeating material covered in the final exams. The informal ‘top tips’ style teaching on the ward from current FY1s was very popular (Table 2, student 14).
DISCUSSION There has been some concern that medical graduates are not adequately prepared for the role of FY1 doctor, in both clinical and non-clinical skills.6,7 Student assistants interviewed in this study and in previous studies have clearly shown that the experience improves preparedness and confidence in the transition from medical student to FY1 doctor.8 Human factors such as familiarisation with their working environment, team members and local protocols are important in patient safety, and should be developed during
undergraduate training.9 In simply learning the names of their multidisciplinary colleagues before starting work, trainees gain self-confidence and feel more comfortable escalating issues to their seniors.10 Teaching sessions during assistantships must be tailored around topics that cause the most anxiety, particularly ‘prescribing’ and ‘emergencies’. Trainees prefer active participation over didactic lectures about what is involved in the role of an FY1.1 In clinical placements throughout medical school students who were made to feel part of the team and given responsibility for tasks felt more confident and prepared for becoming a doctor.1,11 One limitation of this study is that the 20 participants that were interviewed may not be representative of the opinions of the year group. They were purposefully sampled from a group that volunteered to be interviewed, which may represent a particularly proactive
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Table 2. Themes arising from interviews Theme
Quotes
1 Overall evaluation of assistantship
‘It was a really good transition from being a student to an FY1, it provided something we didn’t have before. It’s definitely improved my confidence about the future’ Student 14 ‘It was useful in terms of gaining confidence, but it probably wasn’t as useful as those who were shadowing their actual jobs’ Student 12
2. Understanding their place within the multidisciplinary team
‘It’s worked out really well, he’s [the consultant] really impressed…it’s kind of given me a bit more enthusiasm, a bit more reason to go in and work hard and impress him…’. Student 3 (staying in area) ‘It was really good to get to know the nurses who were all brilliant. I’m looking forward to being on the ward particularly because of the nurses, they were really nice and helpful.’ Student 18 (staying in area) ‘…there is a lot of support for the FY1s…as long as you know where to look for it. So I’m feeling better about that.’ Student 7 (moving out of area) ‘I realised I wouldn’t really be asked to make decisions that could kill someone, those decisions are left to senior people. It’s quite a relief to know.’ Student 13 (staying in area)
3. Developing ‘firstday competences’ under close supervision
‘[The FY1 supervisor] lets me do stuff but at the same time be like, ask me whatever you need, and like she comes to my rescue if it’s out of my ability…’ Student 17 (confident in all domains) ‘For the first week we just observed then we were given responsibility. My FY1 supervisor was good at asking me questions like “How could you make this easier”, which make me think and remember, rather than just telling me…’ Student 13 (moderate anxiety) ‘As a…student you don’t have any responsibility at all, it’s quite a change having responsibility for patients. People respect you more when you say you’ve finished finals and you’re about to become an FY1…Everyone was really supportive and keen to listen to our opinions…’ Student 6 (anxious in all domains) ‘I just wanted to get an idea of what my day-to-day job will be like in August. I pretty much did achieve that…’ Student 2 (moderately anxious)
‘It’s definitely improved my confidence about the future’
4. Prepared for ‘There is not as much generic skills to be gained from the assistantship, there are more sitesite-specific clinical specific skills that you gain. I was investing in making the job easy when I start so I had a competencies drive that others didn’t.’ Student 13 (staying in area) ‘…The systems: who’s good to talk to, who’s not…Here in this hospital I know what consultants I can ring and not be told off for calling them…But when I get to my job I don’t know…I don’t know where the forms are, I don’t know what the policies are. Obviously I need to learn all those things but I’ve just spent six weeks learning them in a completely different location…’ Student 10 (moving out of area) ‘It’s a shame because I’ve had all this but if it was in your hospital then you could be so far ahead and had your induction etc.’ Student 12 (staying in area) 5. Non ward-based teaching
‘Prescribing is an outcome in which I have achieved the most [during the assistantship] and I feel much more confident about it now’ Student 4 (anxious and high expectations that the SA will improve confidence) ‘One thing that they could do better is the prescribing exercises, I think by having 3/4 sessions. I did one and made a couple of mistakes so I would like to build on that, and it would be nice to get into the habit of prescribing things.’ Student 7 (anxious) ‘I couldn’t praise the emergency simulation course enough! I think other students who didn’t get to do that really missed out.’ Student 4 (moderate anxiety in each domain) ‘My FY1 was fantastic…[he] tried to from the start identify areas that he felt he was let down or found difficult when he first started, and tried to warn me about them and prepare me for those situations and scenarios that I will no doubt encounter come August.’ Student 14 (moderate anxiety in each domain)
group. Additionally, two participants (who were not interviewed) only partially completed the questionnaire. Future work to follow on from this study could include case–control studies, comparing the
confidence levels of FY1 doctors who undertook a prolonged assistantship with those that did not, or a follow-up questionnaire to establish whether students’ expectations were met as a whole.
To progress the concept of student assistantships, extensive multicentre piloting will enable the quantification of the impact of the programme on the preparedness and wellbeing of the FY1s, as well as the safety of their patients.
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We propose the implementation of a nationally cohesive programme
Extending the pilot will also enable investigators to evaluate the economic feasibility of such a programme. Despite the incorporation of a local assistantship being currently mandatory in every UK medical school, we propose the implementation of a nationally cohesive programme allowing all students to undertake a prolonged assistantship in their prospective job, even if this is outside the local deanery of their medical school. REFERENCES 1. Catherine B, Matheson DJM, Saunders JH, Howarth C. The views of doctors in their first year of medical practice on the lasting impact of a preparation for house officer course they undertook as final year medical students. BMC Med Educ 2010;10:48. 2. Goldacre MJ, Lambert T, Evans J, Turner G. Pre-registration house officers’ views on whether their experience at medical school prepared them well for their jobs: national questionnaire survey. BMJ 2003;326:1011–1012.
3. General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009. 4. Lempp H, Rees CM. A qualitative study of the perceptions and experiences of Pre-Registration House Officers on teamwork and support. BMC Med Educ 2005;9:10. 5. General Medical Council. Clinical placements for medical student: Advice supplementary to Tomorrow’s Doctors. London: General Medical Council; 2011. 6. Lempp HCM, Seabrook M, Rees J. Impact of educational preparation on medical students in transition from final year to PRHO year: a qualitative evaluation of final-year training following the introduction of a new Year 5 curriculum in a London medical school. Med Teach 2004;26:276–278. 7. Illing JC, Morrow GM, Rothwell nee Kergon CR, et al. Perceptions of UK medical graduates’ preparedness for practice: A multi-centre qualitative study reflecting the importance of learning on the job. BMC Med Educ 2013;13:34. 8. Tong SC, Tin TA, Tan DM, Lim JF. The health related quality of life
of junior doctors. Ann Acad Med Singapore 2012;41:444–450. 9. Flin RPR. Training in non-technical skills to improve patient safety as in aviation, education should occur early in the core curriculum. BMJ 2009;339:985–986. 10. Jones A, Willis SC, McArdle PJ, O’Neill PA. Learning the house officer role: reflections on the value of shadowing a PRHO. Med Teach 2006;28:291–293. 11. Kavanagh P, Boohan M, Savage M, McCluskey D, McKeown P. Evaluation of a Final Year Workshadowing Attachment. Ulster Med J 2012;81:83–88.
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12272/suppinfo Appendix S1. Questionnaire regarding the student assistantship as preparation for foundation year 1.
Corresponding author’s contact details: Dr Elewys Lightman, 28D Hillmarton Road, Holloway, London, N7 9JF, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was sought and granted by the University of Sheffield Ethics Committee. doi: 10.1111/tct.12272
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A prolonged assistantship for final-year students Elewys Lightman1*, Sarah Kingdon2* and Michael Nelson3 1
Department of Clinical Genetics, Northwick Park Hospital, London, UK Oncology Department, The Royal London Hospital, London, UK 3 Department of Medical Education, Sheffield Teaching Hospitals, Sheffield Medical School, UK 2
SUMMARY Background: The transition from medical student to junior doctor is challenging, therefore adequate preparation during medical school is crucial for a smooth transition. Tomorrow’s Doctors expects students to undertake a student assistantship, separate from the local shadowing period prior to commencing employment. Sheffield Medical School initiated a 6–week assistantship within the Yorkshire and Humber deanery. This mixedmethodology study explores this experience from the perspective of final-year medical students.
Methods: Final-year medical students responded to a questionnaire about anxieties surrounding their forthcoming foundation year 1 (FY1). Students were purposefully sampled and semi-structured interviews (SSIs) were conducted, with 20 participants exploring their experience of the assistantship. Interviews were transcribed verbatim and thematic analysis was carried out. Results: The questionnaire results highlighted that most students felt anxious about becoming a FY1 doctor, and subsequent interviews demonstrate that the assistantship
mostly met with students’ expectations. Major themes regarding their anxieties included the value of building professional relationships, familiarisation with the work environment, level of supervision and the value of targeted teaching. Discussion: Student assistantships clearly improve preparedness and confidence in the transition to FY1 by enabling supervised, stepwise responsibility. In the future a nationally cohesive programme should be created for shadowing and assistantships matched with students’ prospective jobs.
Tomorrow’s Doctors expects students to undertake a student assistantship
*Joint first authorship. © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 115–120 115
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‘Shadowing’ periods do not create ample opportunity to assimilate the required nonclinical competencies
INTRODUCTION The transition from medical student to the first year of practising as a qualified doctor, known as foundation year 1 (FY1) in the UK, is renowned as among the most difficult in a doctor’s career. It has been shown that, following the completion of final exams, graduates feel armed with knowledge yet lack confidence in their practical workplace skills.1 A 2000/2001 survey revealed that 42 per cent of newly qualified doctors in the UK felt unprepared by their medical school for their first clinical posts, leading to stress and negatively impacting on doctors’ wellbeing.2
team. Students were based at one of seven centres in the South Yorkshire Deanery, including four district general hospitals and three tertiary referral centres. This study aimed to explore the perceptions of these students on their preparedness for clinical practice following the assistantship.
METHODS
The General Medical Council recommends that all students in the UK undertake ‘shadowing’ (following a junior doctor at work, but without undertaking any duties) in order to familiarise themselves with the local workplace as near to the time of starting work as possible.3 Provisions have been made for all UK doctors to undertake four mandatory paid ‘shadowing’ days immediately prior to starting work; however, ‘shadowing’ periods do not create ample opportunity to assimilate the required nonclinical competencies.4
A short purpose-designed questionnaire (Appendix S1) was developed and piloted with six medical students, to ensure content and face validity of the questions. Figure 1 outlines the study timeline in relation to the student assistantship. The whole year group were invited to complete the questionnaire on day 1. Students self-assessed their anxieties and expected confidence level after the student assistantship, using a Likert scale (1, not at all confident; 5, very confident). Aspects of the FY1 role were categorised; clerking patients, assessing emergencies ward work, clinical skill, and communicating with patients. Questionnaires were not anonymous as participants indicated whether they were happy to be contacted for interview.
The 2009 Tomorrow’s Doctors guidance also recommends a student assistantship (where a student acts as an assistant to a junior doctor, with defined clinical duties under appropriate supervision) towards the end of the undergraduate course to increase students’ preparedness to practice.5 Sheffield Medical School has introduced a 6–week student assistantship for finalyear medical students immediately following their finals. Students were informed as to whether they had passed their exams, but regardless of their result they undertook the programme. Those staying for employment in the area work with their prospective clinical
Purposeful sampling of 20 students was carried out, including at least one participant from each of the seven hospital sites (Table 1). Students’ responses to the questionnaire were investigated carefully, categorising ‘1 or 2’, ‘3 or 4’ or ‘5’ for each domain as ‘anxious’, ‘moderately anxious’ or ‘confident’, respectively. In accordance with the quantitative data (Figure 2), the majority of students invited for interview had indicated that they were anxious or moderately anxious in one or more of the domains investigated (Table 1). Outliers were also targeted to explore the views of those who were either very confident or very anxious.
The majority of students were assistants at tertiary centres, and 55 per cent (11/20) were shadowing their upcoming job (Table 1). Recruitment took place alongside analysis enabling researchers to identify, test and modify themes, and interviews took place between weeks 3 and 6 of the programme. Interviews were recorded and transcribed verbatim, and thematic analysis was carried out independently by two researchers blind to one other. Themes were cross-checked between researchers and then re-coded according to the agreed refined coding frames. Ethical approval was granted by the University of Sheffield.
RESULTS Questionnaire The response rate was 88 per cent (137/156), and the anxiety values reported for each section of the FY1 role are shown in Figure 2. Assessing emergencies was the area students were most anxious about. The majority of students self-reported feeling moderately anxious about each domain of the FY1 role, and expected to become more confident in every section after the assistantship (Figure 2).
116 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 115–120
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Interviews The student assistantship was well received, with the majority of students describing a positive experience; however, those moving to other geographical areas for employment felt that they were at a disadvantage (Table 2, theme 1).
Final exams
Results
Student assistantship (6 weeks)
Week 1 Lectures
Weeks 2–6 Ward-based placement
Day 1 Questionnaire
Students described feeling part of the team and having a sense of purpose
Understanding their place within the multidisciplinary team Students described feeling part of the team and having a sense of purpose. They had not experienced this in previous clinical attachments (Table 2, theme 2), where many felt ‘in the way’ and not useful in contributing to patient care. It appears that these students were longing for some responsibility and a clearly defined role in the workplace. Student 3’s comments illustrate the added motivation to work hard and impress future colleagues (Table 2, theme 2).
Weeks 3–6 Interviews: concurrent sampling and analysis
FY1 year
Figure 1. Timeline of the study in relation to the student assistantship
Table 1. Interview participants details Participant
Site*
Shadowing Reason invited to interview out of area (Y, yes; N, no)
Interviewer
Student 1
1
Y
Anxious (assessing emergencies)
EGL
Student 2
2
Y
Moderate anxiety in each domain EGL
Student 3
3
N
Moderate anxiety in each domain SJK
Student 4
3
N
Anxious and high expectations
Student 5
4
Y
Moderate anxiety in each domain EGL
Student 6
5
Y
Anxious (assessing emergencies)
SJK
Student 7
6
Y
Anxious (all domains)
SJK
Student 8
7
Y
Anxious (assessing emergencies)
SJK
Student 9
3
N
Moderate anxiety in each domain EGL
Student 10
5
Y
Moderate anxiety in each domain SJK
Student 11
5
Y
Anxious (ward work)
Student 12
4
N
Moderate anxiety in each domain SJK
Student 13
5
N
Moderate anxiety in each domain EGL
Student 14
3
N
Moderate anxiety in each domain EGL
Student 15
3
N
Anxious (all domains)
EGL
Student 16
3
N
Anxious (all domains)
EGL
Student 17
1
N
Confident in all domains
SJK
Student 18
4
Y
Moderate anxiety in each domain SJK
Student 19
3
N
Confident in all domains
Student 20
1
Y
Moderate anxiety in each domain EGL
SJK
SJK
EGL
*1, 3, 6, tertiary referral centres; 2, 4, 5, 7, district general hospitals.
Learning how the multidisciplinary team approach is used in decision making helped assistants to appreciate shared responsibility, escalation and who was available to help immediately in the care of patients who are unwell. Both assistants moving out of area and staying in area felt reassured by this (Table 2, theme 2). Some students still indicated that they had fears of making mistakes and causing serious harm. Developing ‘first-day competencies’ under close supervision Graduated responsibility over the assistantship period was effective in improving confidence in their own ability by having constant informal feedback on their work (Table 2, Theme 3). Student 6, who had indicated that they were anxious at the beginning of the student assistantship, felt endorsed by passing their finals and ready to actively contribute to patient care (Table 2). In contrast, some became a little frustrated as they were overly supervised and not encouraged to work independently.
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140
120 Confidence raƟng key
100
Number of parƟcipants
Students who were made to feel part of the team and given responsibility for tasks felt more confident and prepared
5 4 80
3 2
60
1
40
20
0 1
2
Before Predicted PSA aŌer PSA
Confidence regarding admiƫng paƟents
3
4
5
Before Predicted PSA aŌer PSA
6
7
8
9
10
Before Predicted PSA aŌer PSA
Confidence regarding Confidence regarding ward work assessing emergencies
11
12
13
14
Before Predicted PSA aŌer PSA
Before Predicted PSA aŌer PSA
Confidence regarding clinical skills
Confidence regarding communicaƟon with paƟents, families and carers
15
16
17
Before Predicted PSA aŌer PSA
Confidence regarding communicaƟon with colleagues
Figure 2. A clustered bar chart exhibiting the questionnaire results. Participants predicted an increase in confidence ratings in all categories after the prolonged student assistantship (PSA). Confidence ratings were scored from 1 to 5 (1, not at all confident; 5, very confident)
Prepared for site-specific clinical competencies Students recognised that the development of generic or nonclinical skills was imperative for their upcoming role, and often felt that this was easier for those working within their future trust (Table 2, theme 4). Those students working in their prospective jobs benefitted from having log-ins for the trust’s clinical computer programs, enabling them to be familiar with how to use them and more independent in checking investigation results. Non ward-based teaching The assistantship included a workbook of common pitfalls in prescribing for students to complete and review with a clinical pharmacist (Table 2, theme 5). This was popular with student assistants, particularly as many had specified prescribing as an area of concern. Some students wanted further prescribing teaching (Table 2, students 4 and 7). Some hospitals offered a simulation day for emergencies, which was well received by the students who had taken part
(Table 2, student 4). Working through an emergency situation in a non-threatening environment went a long way to prepare students for a real-life situation. Students criticised lecture-based teaching, particularly if the subject was repeating material covered in the final exams. The informal ‘top tips’ style teaching on the ward from current FY1s was very popular (Table 2, student 14).
DISCUSSION There has been some concern that medical graduates are not adequately prepared for the role of FY1 doctor, in both clinical and non-clinical skills.6,7 Student assistants interviewed in this study and in previous studies have clearly shown that the experience improves preparedness and confidence in the transition from medical student to FY1 doctor.8 Human factors such as familiarisation with their working environment, team members and local protocols are important in patient safety, and should be developed during
undergraduate training.9 In simply learning the names of their multidisciplinary colleagues before starting work, trainees gain self-confidence and feel more comfortable escalating issues to their seniors.10 Teaching sessions during assistantships must be tailored around topics that cause the most anxiety, particularly ‘prescribing’ and ‘emergencies’. Trainees prefer active participation over didactic lectures about what is involved in the role of an FY1.1 In clinical placements throughout medical school students who were made to feel part of the team and given responsibility for tasks felt more confident and prepared for becoming a doctor.1,11 One limitation of this study is that the 20 participants that were interviewed may not be representative of the opinions of the year group. They were purposefully sampled from a group that volunteered to be interviewed, which may represent a particularly proactive
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Table 2. Themes arising from interviews Theme
Quotes
1 Overall evaluation of assistantship
‘It was a really good transition from being a student to an FY1, it provided something we didn’t have before. It’s definitely improved my confidence about the future’ Student 14 ‘It was useful in terms of gaining confidence, but it probably wasn’t as useful as those who were shadowing their actual jobs’ Student 12
2. Understanding their place within the multidisciplinary team
‘It’s worked out really well, he’s [the consultant] really impressed…it’s kind of given me a bit more enthusiasm, a bit more reason to go in and work hard and impress him…’. Student 3 (staying in area) ‘It was really good to get to know the nurses who were all brilliant. I’m looking forward to being on the ward particularly because of the nurses, they were really nice and helpful.’ Student 18 (staying in area) ‘…there is a lot of support for the FY1s…as long as you know where to look for it. So I’m feeling better about that.’ Student 7 (moving out of area) ‘I realised I wouldn’t really be asked to make decisions that could kill someone, those decisions are left to senior people. It’s quite a relief to know.’ Student 13 (staying in area)
3. Developing ‘firstday competences’ under close supervision
‘[The FY1 supervisor] lets me do stuff but at the same time be like, ask me whatever you need, and like she comes to my rescue if it’s out of my ability…’ Student 17 (confident in all domains) ‘For the first week we just observed then we were given responsibility. My FY1 supervisor was good at asking me questions like “How could you make this easier”, which make me think and remember, rather than just telling me…’ Student 13 (moderate anxiety) ‘As a…student you don’t have any responsibility at all, it’s quite a change having responsibility for patients. People respect you more when you say you’ve finished finals and you’re about to become an FY1…Everyone was really supportive and keen to listen to our opinions…’ Student 6 (anxious in all domains) ‘I just wanted to get an idea of what my day-to-day job will be like in August. I pretty much did achieve that…’ Student 2 (moderately anxious)
‘It’s definitely improved my confidence about the future’
4. Prepared for ‘There is not as much generic skills to be gained from the assistantship, there are more sitesite-specific clinical specific skills that you gain. I was investing in making the job easy when I start so I had a competencies drive that others didn’t.’ Student 13 (staying in area) ‘…The systems: who’s good to talk to, who’s not…Here in this hospital I know what consultants I can ring and not be told off for calling them…But when I get to my job I don’t know…I don’t know where the forms are, I don’t know what the policies are. Obviously I need to learn all those things but I’ve just spent six weeks learning them in a completely different location…’ Student 10 (moving out of area) ‘It’s a shame because I’ve had all this but if it was in your hospital then you could be so far ahead and had your induction etc.’ Student 12 (staying in area) 5. Non ward-based teaching
‘Prescribing is an outcome in which I have achieved the most [during the assistantship] and I feel much more confident about it now’ Student 4 (anxious and high expectations that the SA will improve confidence) ‘One thing that they could do better is the prescribing exercises, I think by having 3/4 sessions. I did one and made a couple of mistakes so I would like to build on that, and it would be nice to get into the habit of prescribing things.’ Student 7 (anxious) ‘I couldn’t praise the emergency simulation course enough! I think other students who didn’t get to do that really missed out.’ Student 4 (moderate anxiety in each domain) ‘My FY1 was fantastic…[he] tried to from the start identify areas that he felt he was let down or found difficult when he first started, and tried to warn me about them and prepare me for those situations and scenarios that I will no doubt encounter come August.’ Student 14 (moderate anxiety in each domain)
group. Additionally, two participants (who were not interviewed) only partially completed the questionnaire. Future work to follow on from this study could include case–control studies, comparing the
confidence levels of FY1 doctors who undertook a prolonged assistantship with those that did not, or a follow-up questionnaire to establish whether students’ expectations were met as a whole.
To progress the concept of student assistantships, extensive multicentre piloting will enable the quantification of the impact of the programme on the preparedness and wellbeing of the FY1s, as well as the safety of their patients.
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We propose the implementation of a nationally cohesive programme
Extending the pilot will also enable investigators to evaluate the economic feasibility of such a programme. Despite the incorporation of a local assistantship being currently mandatory in every UK medical school, we propose the implementation of a nationally cohesive programme allowing all students to undertake a prolonged assistantship in their prospective job, even if this is outside the local deanery of their medical school. REFERENCES 1. Catherine B, Matheson DJM, Saunders JH, Howarth C. The views of doctors in their first year of medical practice on the lasting impact of a preparation for house officer course they undertook as final year medical students. BMC Med Educ 2010;10:48. 2. Goldacre MJ, Lambert T, Evans J, Turner G. Pre-registration house officers’ views on whether their experience at medical school prepared them well for their jobs: national questionnaire survey. BMJ 2003;326:1011–1012.
3. General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009. 4. Lempp H, Rees CM. A qualitative study of the perceptions and experiences of Pre-Registration House Officers on teamwork and support. BMC Med Educ 2005;9:10. 5. General Medical Council. Clinical placements for medical student: Advice supplementary to Tomorrow’s Doctors. London: General Medical Council; 2011. 6. Lempp HCM, Seabrook M, Rees J. Impact of educational preparation on medical students in transition from final year to PRHO year: a qualitative evaluation of final-year training following the introduction of a new Year 5 curriculum in a London medical school. Med Teach 2004;26:276–278. 7. Illing JC, Morrow GM, Rothwell nee Kergon CR, et al. Perceptions of UK medical graduates’ preparedness for practice: A multi-centre qualitative study reflecting the importance of learning on the job. BMC Med Educ 2013;13:34. 8. Tong SC, Tin TA, Tan DM, Lim JF. The health related quality of life
of junior doctors. Ann Acad Med Singapore 2012;41:444–450. 9. Flin RPR. Training in non-technical skills to improve patient safety as in aviation, education should occur early in the core curriculum. BMJ 2009;339:985–986. 10. Jones A, Willis SC, McArdle PJ, O’Neill PA. Learning the house officer role: reflections on the value of shadowing a PRHO. Med Teach 2006;28:291–293. 11. Kavanagh P, Boohan M, Savage M, McCluskey D, McKeown P. Evaluation of a Final Year Workshadowing Attachment. Ulster Med J 2012;81:83–88.
SUPPORTING INFORMATION Additional supporting information may be found in the online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12272/suppinfo Appendix S1. Questionnaire regarding the student assistantship as preparation for foundation year 1.
Corresponding author’s contact details: Dr Elewys Lightman, 28D Hillmarton Road, Holloway, London, N7 9JF, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was sought and granted by the University of Sheffield Ethics Committee. doi: 10.1111/tct.12272
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