Prescribing
Learning fluid prescription skills: why is it so challenging? Marguerite McCloskey1, Peter Maxwell2 and Gerry Gormley3 1
Department of Medicine, Queens University Belfast, UK Regional Nephrology Unit, Belfast City Hospital, Belfast, UK 3 Centre for Medical Education, Queens University Belfast, UK 2
Medical students and junior doctors find fluid prescription a challenging topic
SUMMARY Background: It is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011–12 at Queen’s University Belfast were invited to participate during their ‘Assistantship’ placement in March 2012. Discussions in focus groups, consisting of between six
and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Results: Five prominent themes emerged: ‘Teaching experience: a disruptive variation’; ‘Curricular disconnections’; ‘The driving test: Theory–practice transformation’; ‘Role modelling: which standard to aspire to?’; and finally ‘Reconciling the perceived risk’. Discussion: This re search provided insights into medical
students’ opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex and contextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novice learner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.
250 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254
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INTRODUCTION
Suboptimal fluid and electrolyte prescription is known to contribute to a range of patient complications
I
ntravenous fluid therapy is often an essential part of patients’ care during their hospitalisation. Suboptimal fluid and electrolyte prescription is known to contribute to a range of patient complications, including fluid overload and electrolyte abnormalities.1 It is recognised that junior doctors find fluid prescription a difficult topic.2 A previous study has documented the poor understanding of the content and administration of intravenous fluids to patients and the indications for using different regimens.2 In one study junior doctors had inadequate knowledge about the prescribing of fluid and electrolytes, with only 56 per cent of respondents, including pre-registration house officers and senior house officers, stating that fluid balance charts were checked on morning ward rounds, and less than half were aware of the normal daily sodium requirement.3 A survey of consultant surgical staff also revealed that in their opinion perioperative fluid management was unsatisfactory amongst their junior staff.4 Furthermore, following the completion of their paediatric attachments, a study of medical students in 2007 revealed that most lacked adequate competency in fluid and electrolyte management, with 81 per cent writing inappropriate fluid prescriptions for a dehydrated infant during the assessment process.5 There is limited research into the specific learning of this essential clinical skill. This was highlighted by Chawla and Drummond, who reviewed the textbook coverage of fluid management and discovered that the information provided in standard textbooks to guide fluid prescription was scant, with wide variation in the suggested quantities of daily fluid, sodium and potassium to
be prescribed.6 There are, however, guidelines available on intravenous fluid prescription. The UK consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) were developed in 2008 and revised in March 2011, and have been endorsed by various subspecialties, including the Association of Surgeons of Great Britain and Ireland and the Intensive Care Society.7 The National Institute for Health and Care Excellence (NICE) have recently published guidelines on intravenous fluid therapy in hospitalised adult patients in December 2013.8 Fluid prescription is an important topic – an essential part of in–patient care – with the potential for significant complications from suboptimal fluid and electrolyte prescriptions.1 This study aimed to gain a greater understanding of the experiences and challenges that final-year medical students face regarding the learning of fluid prescription for hospitalised adult patients, and its application, just prior to their planned transition to
Foundation Year–1 junior doctors.
METHODS Setting The study was conducted at Queen’s University Belfast, where the undergraduate medical programme follows a 5–year integrated curriculum. Just prior to graduating, medical students take part in an 11–week ‘Assistantship’ module where they shadow junior hospital doctors. Ethical approval for this research was obtained in advance from the ethics committee of the medical school. Recruitment and participants During the medical students’ Assistantship module (May 2012, academic year 2011–12), students were invited to take part in this study on a voluntary basis. This sampling point was chosen in order to obtain students’ experiences as they approached completion of their undergraduate training. A convenience sampling method was used to select students to take part in focus groups consisting of between six and eight participants per group.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254 251
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Students frequently expressed the opinion that the teaching of fluid prescription varied considerably
Data collection Focus groups were facilitated by two researchers using a questioning guide, constructed following a literature review of the evidence base regarding the learning and prescribing of fluids. Neither of the researchers were directly involved in the teaching of fluid prescription to the students. A total of 32 medical students participated in five focus groups. Participants were 22–28 years of age, and 20 were female and 12 were male. Data saturation was reached after five focus groups when no new themes emerged. Each focus group lasted 30–40 minutes and group discussions were digitally recorded, anonymised and transcribed verbatim. Data analysis The research team, consisting of three separate investigators, performed thematic analysis independently. Analysis and data collection followed an interactive process in which memo writing and constant comparison was used until a final consensus regarding emerging themes was reached by the entire research team.
‘Curricular disconnections’ was another prominent theme, where in the students’ view there was insufficient vertical and horizontal integration of the teaching between and within years, and some suggested the use of a manual to maintain consistency of teaching. ‘The driving test: theory–practice transformation’ was another emerging theme, where the students perceived a difference between what is taught in theory and what happens in practice, with one student using the driving test analogy of some not always practising what they are taught when applying theory in practice, and some suggesting the possibility of overprescribing when theory is applied in some settings. ‘Role modelling: which standard to aspire to?’ was an important theme, where students regarded the doctors on the ward as being role models. Students had difficulty judging which standard to aspire to: the method that they had been taught as an undergraduate or the method of fluid prescription that they had witnessed on the ward.
DISCUSSION This study highlights medical students’ opinions towards the teaching practices and learning experiences of fluid prescribing, and has added new insights into why students find fluid prescription a difficult topic. There is a continuum of learning about fluid prescription from undergraduate theoretical knowledge through to postgraduate practical applied knowledge, and there are many influences on this learning that have been identified through this qualitative research. Various factors influence how students learn, including variation in teaching methods, disparity in practice between specialties and the lack of curricular integration as an undergraduate. The influence of role modelling on the learning and subsequent prescribing practices of medical students appeared to play an important role, as did the media attention at the time this study was conducted. Each of these aspects of learning should be taken into consideration when making recommendations for improvement in the teaching and learning of fluid prescription, including future research.
RESULTS This study provided evidence of the complexity and contextual nature of fluid prescription, and of its teaching, with a variety of factors that can influence the learning of fluid prescription. Five prominent themes emerged from the focus group analysis. Examples of students’ opinions demonstrating each of the themes are included in Table 1. ‘Teaching experience: a disruptive variation’ was a major theme, where the students frequently expressed the opinion that the teaching of fluid prescription varied considerably, not only within and between years, but also across specialties. Examples of students’ opinions are included in Table 1.
‘Reconciling the perceived risk’ was the final theme, where the students expressed a conflict between the risks associated with fluid prescription, highlighted in the media and in the teaching that they had received, and what they perceive happens in real life on the wards (Table 1). At the time this study was conducted there had been significant media attention locally on deaths related to hyponatraemia and the impact of fluid prescription, particularly in children. The students were alerted to the potential risks associated with fluid prescription, but they perceived its priority on the ward was lower than it should have been because of time constraints for prescribing doctors.
RECOMMENDATIONS This research has identified a number of areas where improvements could be made regarding the teaching and learning of fluid prescription, and each will require further research in an effort to determine the efficacy of any intervention made (Table 2). They echo many of the recommendations made by Dornan et al. regarding safe medication prescribing,9 which reflects that improved fluid prescription skills are relevant to other learning situations, such as clinical assessment of patients and safe medication prescription. Study limitations A convenience sampling method was used, which may have
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Table 1. Examples of students’ opinions to demonstrate themes Theme
Students’ opinions
Teaching experience: a disruptive variation
I have found it inconsistent in the teaching that I have received. The best teaching was in fourth year in the peri-operative and emergency medicine (POEM) module, but then you go out onto the ward, for example a surgical ward, and someone says, just look at the patient and decide how much they need and don’t use all those figures and formulas, so it is kind of hard to know what approach to use. Focus group 2
It would have been valuable to compare the results with the experience of students from other medical schools
There is such huge inconsistency in how we are taught about it from third year, fourth year, and now this year, and nobody wants to say this is the right way… Focus group 1 ‘Curricular disconnections’
I think there needs to be more consistency in what we are taught from the start, and that is taught right through from third, fourth and final year, rather than introducing lots of different methods… Focus group 4 I think it would be useful to be taught with a manual for your attachments in medicine and surgery, so the doctors know that that is the way you are taught as well… Focus group 2
The driving test: theory–practice transformation
It kind of reminds me of the driving test, you do everything perfectly in your driving test, but when you are out on the roads it is different really. So even F1s, in the short time that we have been here, we have seen fluid prescribed differently, it may be more of an imperfect science, but it still gets the job done…just like you would be on the roads, where you would not be looking all around you anymore…’ Focus group 1 In practice you don’t go through those steps of shock, deficit, maintenance, losses, which sometimes overprescribes, I mean you give way too much fluid, and you could end up with seven or something litres, and you never see that written up… Focus group 1
Role modelling: which standard to aspire to?
I would probably just go along with what you see the F1s do…I mean, you see them working in their jobs, and you think, oh that’s me next year…and you think…if you do what they do, you will be sound… Focus group 1 What they do is quite influential…I suppose the junior staff just look at the previous days fluids, like how much the previous person has prescribed, and if the patient is ok, then they just do the same thing again…I would probably do the same as what they do and copy them Focus group 5
Reconciling the perceived risk
I think it is more that there is so much hype about it, that you think it is really bad… Focus group 3 …It is just making the realisation…when you are working you don’t have much time, and it comes down on your priorities to get it exact because in fluid prescribing you are allowed to fluctuate how much you give, it doesn’t have to be to the last ml like we have been taught… Focus group 2
F1, foundation year 1 trainee, i.e. a junior doctor within 1 year of medical school graduation.
resulted in self-selection bias. The study was undertaken in one medical school, leading to a potential lack of generalisability of the results. It would have been valuable to compare results with the experience of students from other medical schools. The study could also have been limited by facilitator bias, as students may have been reluctant to disclose
information to doctors involved in undergraduate education. Future research This study could be extended to other medical schools and foundation year trainees to sample their attitudes towards fluid prescription and the comparison between undergraduate and postgraduate experiences. The
study could also be extended to include the opinions of teachers on fluid prescription, particularly the variation between different specialties. Further research could also be conducted to determine any differences in the knowledge base of medical students on fluid prescription, and compare that with knowledge application and the learning environment.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254 253
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Students should ..be willing to seek help and challenge prescriptions that they believe to be incorrect
Table 2. Summary of recommendations for improvement in the teaching and learning of fluid prescription Recommendation
Description
Clinical working environment
Factors related to the clinical working environment and time constraints were often mentioned, and one recommendation would be a standard fluid prescription chart across all hospitals, which would involve discussion with clinical leads.
Undergraduate medical education
The differences between the method of fluid prescription in theory and practice were often mentioned, and one recommendation would be to include more practical prescribing under supervision, linking theory with practice at the time the theory is taught. Students should also be encouraged to be open to feedback, be willing to seek help and challenge prescriptions that they believe to be incorrect.
Foundation-year programme education
It was often mentioned that the foundation-year trainees did most of the prescribing of fluids. One recommendation would be to further develop fluid prescription training for foundation-year trainees as part of their generic skills education, to further reinforce the importance of fluid prescription.
CONCLUSION This study has provided insights into medical students’ opinions towards the teaching practices and learning experiences of fluid prescribing. The study also highlights why students may find fluid prescription a difficult topic, and generated a number of recommendations and ideas for future research, in an effort to improve fluid prescribing and teaching.
intravenous fluids. BMJ 2011;342:d2741. 3.
Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr 2001;20:125–130.
4.
Lobo DN, Dube MG, Neal KR, Allison SP, Rowlands BJ. Perioperative fluid and electrolyte management: a survey of consultant surgeons in the UK. Ann R Coll Surg Engl 2002;84:156–160.
5.
Weisgerber M, Flores G, Pomeranz A, Greenbaum L, Hurlbut P, Bragg D. Student competence in fluid and electrolyte management: the impact of various teaching methods. Ambul Pediatr 2007;7:220–225.
6.
Chawla G, Drummond GB. Textbook coverage of a common topic: fluid management of patients after surgery. Med Educ 2008;42:613–618.
REFERENCES 1.
2.
Walsh SR, Walsh CJ. Intravenous fluid-associated morbidity in postoperative patients. Ann R Col Surg Engl 2005;87:126–130. Powell AGMT, Paterson-Brown S. FY1 doctors still poor in prescribing
7.
Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M, Lewington AJ, Pearse RM, Mythen MG. British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP). 2011. Available at http://www.bapen.org. uk/pdfs/bapen_pubs/giftasup.pdf. Accessed September 2013.
8.
National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in adults in hospital. Available at http://www.nice.org. uk/guidance/CG174. Accessed December 2013.
9.
Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. FINAL report: An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2012. Available at http://www.gmc-uk.org/FINAL_ Report_prevalence_and_causes_of_ prescribing_errors.pdf_28935150. pdf. Accessed September 2013.
Corresponding author’s contact details: Dr Marguerite McCloskey, Department of Medicine, Queens University Belfast, Belfast, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval for this research was obtained in advance from Queens University of Belfast Medical Schools Ethics Committee. doi: 10.1111/tct.12306
254 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254
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Learning fluid prescription skills: why is it so challenging? Marguerite McCloskey1, Peter Maxwell2 and Gerry Gormley3 1
Department of Medicine, Queens University Belfast, UK Regional Nephrology Unit, Belfast City Hospital, Belfast, UK 3 Centre for Medical Education, Queens University Belfast, UK 2
Medical students and junior doctors find fluid prescription a challenging topic
SUMMARY Background: It is well recognised that medical students and junior doctors find fluid prescription a challenging topic. This study was designed to gain a greater understanding of the experiences that medical students face related to learning about fluid prescribing. Methods: A qualitative approach, using focus groups, was employed in this research. Final-year medical students in academic year 2011–12 at Queen’s University Belfast were invited to participate during their ‘Assistantship’ placement in March 2012. Discussions in focus groups, consisting of between six
and eight students, were recorded and transcribed verbatim. The research team, consisting of three separate investigators, conducted thematic analysis independently. A final consensus regarding emerging themes was reached by discussion within the whole research team. Results: Five prominent themes emerged: ‘Teaching experience: a disruptive variation’; ‘Curricular disconnections’; ‘The driving test: Theory–practice transformation’; ‘Role modelling: which standard to aspire to?’; and finally ‘Reconciling the perceived risk’. Discussion: This re search provided insights into medical
students’ opinions of the teaching practices and learning experiences related to fluid prescribing. The learning of prescribing skills is complex and contextual. In the development of such skills, medical students are often exposed to conflicting educational experiences that challenge the novice learner in making judgements on best prescribing practice. This study adds to the body of evidence that fluid prescription is a difficult topic, and has generated a number of multifaceted and strategic recommendations to potentially improve fluid prescription teaching.
250 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254
tct_12306.indd 250
6/19/2015 7:39:18 AM
INTRODUCTION
Suboptimal fluid and electrolyte prescription is known to contribute to a range of patient complications
I
ntravenous fluid therapy is often an essential part of patients’ care during their hospitalisation. Suboptimal fluid and electrolyte prescription is known to contribute to a range of patient complications, including fluid overload and electrolyte abnormalities.1 It is recognised that junior doctors find fluid prescription a difficult topic.2 A previous study has documented the poor understanding of the content and administration of intravenous fluids to patients and the indications for using different regimens.2 In one study junior doctors had inadequate knowledge about the prescribing of fluid and electrolytes, with only 56 per cent of respondents, including pre-registration house officers and senior house officers, stating that fluid balance charts were checked on morning ward rounds, and less than half were aware of the normal daily sodium requirement.3 A survey of consultant surgical staff also revealed that in their opinion perioperative fluid management was unsatisfactory amongst their junior staff.4 Furthermore, following the completion of their paediatric attachments, a study of medical students in 2007 revealed that most lacked adequate competency in fluid and electrolyte management, with 81 per cent writing inappropriate fluid prescriptions for a dehydrated infant during the assessment process.5 There is limited research into the specific learning of this essential clinical skill. This was highlighted by Chawla and Drummond, who reviewed the textbook coverage of fluid management and discovered that the information provided in standard textbooks to guide fluid prescription was scant, with wide variation in the suggested quantities of daily fluid, sodium and potassium to
be prescribed.6 There are, however, guidelines available on intravenous fluid prescription. The UK consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP) were developed in 2008 and revised in March 2011, and have been endorsed by various subspecialties, including the Association of Surgeons of Great Britain and Ireland and the Intensive Care Society.7 The National Institute for Health and Care Excellence (NICE) have recently published guidelines on intravenous fluid therapy in hospitalised adult patients in December 2013.8 Fluid prescription is an important topic – an essential part of in–patient care – with the potential for significant complications from suboptimal fluid and electrolyte prescriptions.1 This study aimed to gain a greater understanding of the experiences and challenges that final-year medical students face regarding the learning of fluid prescription for hospitalised adult patients, and its application, just prior to their planned transition to
Foundation Year–1 junior doctors.
METHODS Setting The study was conducted at Queen’s University Belfast, where the undergraduate medical programme follows a 5–year integrated curriculum. Just prior to graduating, medical students take part in an 11–week ‘Assistantship’ module where they shadow junior hospital doctors. Ethical approval for this research was obtained in advance from the ethics committee of the medical school. Recruitment and participants During the medical students’ Assistantship module (May 2012, academic year 2011–12), students were invited to take part in this study on a voluntary basis. This sampling point was chosen in order to obtain students’ experiences as they approached completion of their undergraduate training. A convenience sampling method was used to select students to take part in focus groups consisting of between six and eight participants per group.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254 251
tct_12306.indd 251
6/19/2015 7:39:22 AM
Students frequently expressed the opinion that the teaching of fluid prescription varied considerably
Data collection Focus groups were facilitated by two researchers using a questioning guide, constructed following a literature review of the evidence base regarding the learning and prescribing of fluids. Neither of the researchers were directly involved in the teaching of fluid prescription to the students. A total of 32 medical students participated in five focus groups. Participants were 22–28 years of age, and 20 were female and 12 were male. Data saturation was reached after five focus groups when no new themes emerged. Each focus group lasted 30–40 minutes and group discussions were digitally recorded, anonymised and transcribed verbatim. Data analysis The research team, consisting of three separate investigators, performed thematic analysis independently. Analysis and data collection followed an interactive process in which memo writing and constant comparison was used until a final consensus regarding emerging themes was reached by the entire research team.
‘Curricular disconnections’ was another prominent theme, where in the students’ view there was insufficient vertical and horizontal integration of the teaching between and within years, and some suggested the use of a manual to maintain consistency of teaching. ‘The driving test: theory–practice transformation’ was another emerging theme, where the students perceived a difference between what is taught in theory and what happens in practice, with one student using the driving test analogy of some not always practising what they are taught when applying theory in practice, and some suggesting the possibility of overprescribing when theory is applied in some settings. ‘Role modelling: which standard to aspire to?’ was an important theme, where students regarded the doctors on the ward as being role models. Students had difficulty judging which standard to aspire to: the method that they had been taught as an undergraduate or the method of fluid prescription that they had witnessed on the ward.
DISCUSSION This study highlights medical students’ opinions towards the teaching practices and learning experiences of fluid prescribing, and has added new insights into why students find fluid prescription a difficult topic. There is a continuum of learning about fluid prescription from undergraduate theoretical knowledge through to postgraduate practical applied knowledge, and there are many influences on this learning that have been identified through this qualitative research. Various factors influence how students learn, including variation in teaching methods, disparity in practice between specialties and the lack of curricular integration as an undergraduate. The influence of role modelling on the learning and subsequent prescribing practices of medical students appeared to play an important role, as did the media attention at the time this study was conducted. Each of these aspects of learning should be taken into consideration when making recommendations for improvement in the teaching and learning of fluid prescription, including future research.
RESULTS This study provided evidence of the complexity and contextual nature of fluid prescription, and of its teaching, with a variety of factors that can influence the learning of fluid prescription. Five prominent themes emerged from the focus group analysis. Examples of students’ opinions demonstrating each of the themes are included in Table 1. ‘Teaching experience: a disruptive variation’ was a major theme, where the students frequently expressed the opinion that the teaching of fluid prescription varied considerably, not only within and between years, but also across specialties. Examples of students’ opinions are included in Table 1.
‘Reconciling the perceived risk’ was the final theme, where the students expressed a conflict between the risks associated with fluid prescription, highlighted in the media and in the teaching that they had received, and what they perceive happens in real life on the wards (Table 1). At the time this study was conducted there had been significant media attention locally on deaths related to hyponatraemia and the impact of fluid prescription, particularly in children. The students were alerted to the potential risks associated with fluid prescription, but they perceived its priority on the ward was lower than it should have been because of time constraints for prescribing doctors.
RECOMMENDATIONS This research has identified a number of areas where improvements could be made regarding the teaching and learning of fluid prescription, and each will require further research in an effort to determine the efficacy of any intervention made (Table 2). They echo many of the recommendations made by Dornan et al. regarding safe medication prescribing,9 which reflects that improved fluid prescription skills are relevant to other learning situations, such as clinical assessment of patients and safe medication prescription. Study limitations A convenience sampling method was used, which may have
252 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254
tct_12306.indd 252
6/19/2015 7:39:28 AM
Table 1. Examples of students’ opinions to demonstrate themes Theme
Students’ opinions
Teaching experience: a disruptive variation
I have found it inconsistent in the teaching that I have received. The best teaching was in fourth year in the peri-operative and emergency medicine (POEM) module, but then you go out onto the ward, for example a surgical ward, and someone says, just look at the patient and decide how much they need and don’t use all those figures and formulas, so it is kind of hard to know what approach to use. Focus group 2
It would have been valuable to compare the results with the experience of students from other medical schools
There is such huge inconsistency in how we are taught about it from third year, fourth year, and now this year, and nobody wants to say this is the right way… Focus group 1 ‘Curricular disconnections’
I think there needs to be more consistency in what we are taught from the start, and that is taught right through from third, fourth and final year, rather than introducing lots of different methods… Focus group 4 I think it would be useful to be taught with a manual for your attachments in medicine and surgery, so the doctors know that that is the way you are taught as well… Focus group 2
The driving test: theory–practice transformation
It kind of reminds me of the driving test, you do everything perfectly in your driving test, but when you are out on the roads it is different really. So even F1s, in the short time that we have been here, we have seen fluid prescribed differently, it may be more of an imperfect science, but it still gets the job done…just like you would be on the roads, where you would not be looking all around you anymore…’ Focus group 1 In practice you don’t go through those steps of shock, deficit, maintenance, losses, which sometimes overprescribes, I mean you give way too much fluid, and you could end up with seven or something litres, and you never see that written up… Focus group 1
Role modelling: which standard to aspire to?
I would probably just go along with what you see the F1s do…I mean, you see them working in their jobs, and you think, oh that’s me next year…and you think…if you do what they do, you will be sound… Focus group 1 What they do is quite influential…I suppose the junior staff just look at the previous days fluids, like how much the previous person has prescribed, and if the patient is ok, then they just do the same thing again…I would probably do the same as what they do and copy them Focus group 5
Reconciling the perceived risk
I think it is more that there is so much hype about it, that you think it is really bad… Focus group 3 …It is just making the realisation…when you are working you don’t have much time, and it comes down on your priorities to get it exact because in fluid prescribing you are allowed to fluctuate how much you give, it doesn’t have to be to the last ml like we have been taught… Focus group 2
F1, foundation year 1 trainee, i.e. a junior doctor within 1 year of medical school graduation.
resulted in self-selection bias. The study was undertaken in one medical school, leading to a potential lack of generalisability of the results. It would have been valuable to compare results with the experience of students from other medical schools. The study could also have been limited by facilitator bias, as students may have been reluctant to disclose
information to doctors involved in undergraduate education. Future research This study could be extended to other medical schools and foundation year trainees to sample their attitudes towards fluid prescription and the comparison between undergraduate and postgraduate experiences. The
study could also be extended to include the opinions of teachers on fluid prescription, particularly the variation between different specialties. Further research could also be conducted to determine any differences in the knowledge base of medical students on fluid prescription, and compare that with knowledge application and the learning environment.
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254 253
tct_12306.indd 253
6/19/2015 7:39:28 AM
Students should ..be willing to seek help and challenge prescriptions that they believe to be incorrect
Table 2. Summary of recommendations for improvement in the teaching and learning of fluid prescription Recommendation
Description
Clinical working environment
Factors related to the clinical working environment and time constraints were often mentioned, and one recommendation would be a standard fluid prescription chart across all hospitals, which would involve discussion with clinical leads.
Undergraduate medical education
The differences between the method of fluid prescription in theory and practice were often mentioned, and one recommendation would be to include more practical prescribing under supervision, linking theory with practice at the time the theory is taught. Students should also be encouraged to be open to feedback, be willing to seek help and challenge prescriptions that they believe to be incorrect.
Foundation-year programme education
It was often mentioned that the foundation-year trainees did most of the prescribing of fluids. One recommendation would be to further develop fluid prescription training for foundation-year trainees as part of their generic skills education, to further reinforce the importance of fluid prescription.
CONCLUSION This study has provided insights into medical students’ opinions towards the teaching practices and learning experiences of fluid prescribing. The study also highlights why students may find fluid prescription a difficult topic, and generated a number of recommendations and ideas for future research, in an effort to improve fluid prescribing and teaching.
intravenous fluids. BMJ 2011;342:d2741. 3.
Lobo DN, Dube MG, Neal KR, Simpson J, Rowlands BJ, Allison SP. Problems with solutions: drowning in the brine of an inadequate knowledge base. Clin Nutr 2001;20:125–130.
4.
Lobo DN, Dube MG, Neal KR, Allison SP, Rowlands BJ. Perioperative fluid and electrolyte management: a survey of consultant surgeons in the UK. Ann R Coll Surg Engl 2002;84:156–160.
5.
Weisgerber M, Flores G, Pomeranz A, Greenbaum L, Hurlbut P, Bragg D. Student competence in fluid and electrolyte management: the impact of various teaching methods. Ambul Pediatr 2007;7:220–225.
6.
Chawla G, Drummond GB. Textbook coverage of a common topic: fluid management of patients after surgery. Med Educ 2008;42:613–618.
REFERENCES 1.
2.
Walsh SR, Walsh CJ. Intravenous fluid-associated morbidity in postoperative patients. Ann R Col Surg Engl 2005;87:126–130. Powell AGMT, Paterson-Brown S. FY1 doctors still poor in prescribing
7.
Powell-Tuck J, Gosling P, Lobo DN, Allison SP, Carlson GL, Gore M, Lewington AJ, Pearse RM, Mythen MG. British consensus guidelines on intravenous fluid therapy for adult surgical patients (GIFTASUP). 2011. Available at http://www.bapen.org. uk/pdfs/bapen_pubs/giftasup.pdf. Accessed September 2013.
8.
National Institute for Health and Care Excellence (NICE). Intravenous fluid therapy in adults in hospital. Available at http://www.nice.org. uk/guidance/CG174. Accessed December 2013.
9.
Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. FINAL report: An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. 2012. Available at http://www.gmc-uk.org/FINAL_ Report_prevalence_and_causes_of_ prescribing_errors.pdf_28935150. pdf. Accessed September 2013.
Corresponding author’s contact details: Dr Marguerite McCloskey, Department of Medicine, Queens University Belfast, Belfast, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval for this research was obtained in advance from Queens University of Belfast Medical Schools Ethics Committee. doi: 10.1111/tct.12306
254 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 250–254
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