Background: Prescription medicines are a common healthcare intervention. Although medicines are often beneficial in controlling effects of disease and preventing mortality, some people have negative experiences with medicines use. Health professionals often prioritise actual or anticipated treatment benefits above any associated psychosocial or practical burdens patients may experience when using medicines. There is a need for generic, valid and reliable patient-reported tools to evaluate varying experiences of using medicines and associated burden. Aim: This thesis focusses on instrument development, revision and validation of a novel generic patient-reported measure of prescription medicine burden, the Living with Medicines Questionnaire (LMQ). Methods: A systematic literature review was conducted to confirm the suitability of the LMQ-1 as a relevant measure for development. This was followed by a pragmatic, iterative, mixed methodological approach, including qualitative interviews and surveys that were used in further development and validation of this instrument. Across all studies, participants were adults, using long-term prescription medicines, and were recruited face-to-face from community pharmacies, general practices, outpatient clinics and public areas in south-east England, or on-line across England. Principal components analysis of responses to the LMQ-1 enabled preliminary item reduction, and revealed gaps in the resulting 42-item version (the LMQ-2). To cover missing domains, new item generation and semi-structured, cognitive interviews led to an interim, 58-item, LMQ-2.1 ensuring that meanings of all statements were as intended. Final item reduction and confirmatory factor analyses of responses to the LMQ-2.1 established the 41-item LMQ-3 as the final agreed instrument. Criterion-related validation of the LMQ-3 ascertained relationships among medicine burden concepts, treatment satisfaction and health-related quality of life (HRQoL). Internal consistency (Cronbach's alpha) and test-retest reliability (intraclass correlation coefficients, ICCs) were also examined. LMQ-3 composite scores were used to define levels of burden, while regression analyses assessed predictors of medicine burden. Results: The systematic review identified the original 60-item LMQ-1 as a relevant measure based on patient-generated concepts, but which required extensive modification and testing, including content addition. The final 41-item LMQ-3 instrument covers eight domains, under an overarching construct of medicine burden: interferences with day-to-day life; patient-doctor relationships and communication about medicines; lack of effectiveness; general concerns; side effects; practical difficulties; cost-related burden, and lack of autonomy/control over medicines use. Cronbach's alpha (0.61-0.90) and ICC values (0.73-0.93) were satisfactory for most subscales. Medicine burden was established as a distinct concept negatively associated with treatment satisfaction and HRQoL. Higher-level medicine burden, estimated at 10% prevalence for the English adult population, was associated with age < 65 years, unemployment, residence in areas with higher relative level of deprivation, more frequent medicine use and combinations of formulations, but was not clearly related to the number of medicines. Conclusion: The LMQ-3 is a relatively comprehensive, valid, reliable, and interpretable measure of medicines burden suitable for use among adults using long-term medicines for any disease/condition (s) in England. The instrument could be used to identify those with high medicines burden or in studies of healthcare interventions aimed at the prevention, and/or reduction of medicine burden.

In recent years there has been much research into the roles of doctor and patient and the nature of the interaction between them. Research has shown that certain identifiable and fixed roles 'are evident within the doctor-patient relationship. However, these roles are perhaps less 'fixed' than previously thought and it can be argued that the roles and relationship have evolved over time, with significant changes taking place more recently.

Background: The UK’s National Health Service (NHS) currently relies on overseas doctors to ensure effective healthcare delivery. However, concern has grown around their regulation and practice and there is a recognition of the need to support overseas qualified doctors to make a successful transition to the NHS. Interventions have been implemented to address transitional issues without sufficient exploration of what is likely to work or how much training and support are appropriate. The absence of a supportive framework, targeting social, cultural and work related issues, has led to overseas graduates feeling stressed, being isolated and experiencing mental health issues. Difficulties in career progression, retention and performance are also evident. This thesis explores and evaluates interventions that have been developed to support the transition of overseas medical graduates to the UK. Method: A realist approach was adopted. A realist synthesis (exploration of literature and development of initial theory) was conducted. A realist evaluation was then completed to test and refine theory. The main intervention subject was the Programme for Overseas Doctors (POD) developed within one North East Trust. A comparative case study design, using mixed methods, was used (including interviews, questionnaires, researcher observation and analysis of performance data). Findings: A synthesis of the findings, including 123 interviews, illustrated that three key contextual levels; organisational, training and individual, will likely impact on the adjustment of overseas doctors (including performance, retention, career progression and wellbeing). One of the main outcomes of this thesis is a transferable, theoretical explanation of how interventions can successfully support the transition of overseas medical graduates to the NHS. Conclusions: In order to successfully support the transition of overseas doctors, interventions need to be more comprehensive and broad ranging than a simple induction or one-off training programme. Interventions must focus on building an open and supportive culture, address individual needs, and include ongoing support from all staff beyond the initial intervention. This work has reviewed factors that contribute to a successful intervention and has put forward recommendations for future policy, interventions and future research.

Background: Specialty training is a stressful period in medical training. Trainees must work in a busy clinical environment and meet their training competencies. Trainees must complete an annual review to ensure that they are competent to pass to the next level of training. This thesis is interested in why some trainees (5%) have difficulties progressing through their training. Factors which impact on trainees’ performance are complex and multiple in nature. It may start with their personality or country of graduation (or both). Secondly, it may be that trainees have not received adequate feedback and this has contributed to their underperformance or, thirdly, the service demands and work intensity impact on a trainee’s ability to progress. An in-depth understanding of the factors and how they interact with each other and impact on trainees underperforming is needed. Aim: This thesis set out to identify the factors that either facilitate or hinder medical specialty trainees in their Annual Review of Competence Progression (ARCP), with a focus on adverse ARCP outcomes. Methods: Research was conducted across three phases. Phase One was a retrospective observational study investigating which trainees had difficulty progressing through their ARCPs (over a five year period). Phase Two was a systematic literature review to identify indicators that are associated with doctors who experience difficulties with progressing during their specialty training. Phase Three involved a constructivist Grounded Theory study to provide further understanding about what helped or hindered ARCP outcomes. Results: Findings from Phase One identified that trainees who were older, male or had qualified overseas were found to be at a greater risk of receiving adverse ARCP outcomes. Phase Two identified seven indicators from the literature, these were: overseas graduates and ethnicity, age, gender, personality traits, financial issues, trainee background and issues related to the organisation. Phase Three involved semi-structured interviews with trainees (n=21) and trainers (n=57). Interviews identified risk factors and enablers to progressing through specialty training. The three core categories identified were: individual, training environment and society. Associated risks and enablers were also identified under each of these three core categories. The overall core category, which emerged from the data and explained why trainees had difficulties progressing was focused on a conflict of values. A ‘values model’ was developed to explain why trainees fail their ARCPs. Discussion: The synthesis of all Phases of this thesis, informed the development of a ‘circuit’ model that identified the barriers and enablers to trainee progression (Phase Four). In addition, a screening tool was devised to help Trusts with the early identification of trainees most at risk of adverse ARCP outcomes, and ensure enabling factors are made available to support trainees. Conclusion: This thesis has identified why trainees fail ARCPs (conflict in values), the barriers and enablers to progression and has developed a tool to support the early identification of trainees most at risk.

No description available.

No description available.

This enquiry concerns the professional identities of newly qualified doctors, exploring how early years practitioners form their sense of self-as-doctor and the structural, educational, social and personal influences on this formation. With identity formation and professional development framed as situated, socio-cultural and developed within and through practice as an iterative process of becoming, this qualitative study, conducted in the interpretivist tradition, uses life-history interviews and brief periods of observation with recently qualified doctors. It reveals that new doctors begin to establish their professional identities through the interlinked processes of learning, belonging and becoming. Developing professional competencies, learning 'medicine' and a re-contextualisation of existing knowledge allows them to 'figure' who they are and what is expected of them. Belonging, although always partial, affects not only what can be made of experiences but also what can be carried forward. Becoming orientated to being a 'good doctor' has both outward-facing and personal aspects and is stimulated by responsibility, influenced by the personal history and planned trajectory of the doctor and the affordances of workplaces and delayed by the fragmented nature of the early years of work. Much of this learning, attempting to belong and to become a good doctor is not directed at their eventual doctor role but at the here and now. This work provides telling insights into the socio-cultural dimension of becoming a doctor and the potential effects of recent workplace and education reform on identity, professional formation and ultimately, practice. It provides ways of theorising how medical professional identities develop, questioning notions of a simple novice to expert trajectory and suggesting novice doctors maintain a legitimately peripheral period of participation in their communities during the early years of work. Both pedagogical approaches in medical education and the conceptualisation of the medical workplace as a site of learning and formation would benefit from review in light of these findings.

Good judgement and the ability to make complex decisions are key attributes of a skilled professional. The study aims were to understand how training doctors develop practical wisdom through investigating their approach to difficult decision making, understanding the influences on the development of these skills, and identifying potential interventions that may help develop these skills further. The background literature explores current understanding of professional development and clinical thinking frameworks. Methodology The study adopted an approach of social constructivism, constructing an understanding of the process of developing practical wisdom. The study investigated training doctors at different stages of their career. Qualitative interviews were used to explore the approaches doctors take to difficult decision making as well as the key training influences in learning these skills. Results Thematic data analysis has led to the construction of a conceptual model which sets out the development of practical wisdom among training doctors. This model describes a process of gaining experience in decision making, moderated by key external and internal influences. The important roles of self-efficacy, agency (relational) and structure are highlighted as key enablers of this process. Discussion There has been limited study of doctors and their decision making, particularly in relation to complex decisions. The implications of this model are considered in relation to postgraduate training of doctors. The importance of training doctors as self-regulated learners in learning environments that support their development is highlighted. Aspects of the clinical learning environment (structure) such as rotation structures, the culture, supervision and feedback can all be enhanced. Self-efficacy and relational agency, alongside other internal influences, are key factors in accelerating development of practical wisdom that can be improved with targeted interventions.

Since its inception in 2003, the Patient Voices Programme has been gathering and disseminating digital stories of healthcare created by patients, carers and clinicians involved in delivering and receiving that care. It is one of the longest-running digital storytelling projects in the world and, as far as can be determined, the only digital storytelling project to focus specifically on healthcare. During this time, more than 1000 digital stories have been created. Once released by storytellers, these stories are made freely available by a publicly accessible website for use in healthcare education and service improvement programmes. The aim of Patient Voices was, through sharing the stories of what really matters to the people who design, deliver and receive healthcare, to bring about a transformation, resulting in safer, higher quality care characterised by greater humanity and compassion. I am one of the founders of the Patient Voices Programme. I have played a key role in every aspect of the Programme’s development, from working with the first storytellers and writing the original rationale, to conducting research on the impact of the stories, presenting at numerous conferences, writing papers for publication, facilitating workshops and consulting on use of the stories. Not only has the Patient Voices Programme had an impact on the world of healthcare, particularly in the UK, but it has also had an impact on the wider world of digital storytelling, where the Patient Voices Programme is regarded as the world leader in digital storytelling in healthcare; indeed, I have given a keynote address at four of the last five international digital storytelling conferences. Through an examination of eight published papers and the Patient Voices website, this thesis will demonstrate the contribution that I have made, through the Patient Voices Programme, to healthcare and healthcare education as well as to the wider, emerging field of digital storytelling.

This thesis presents a retrospective case study that critically examines the evaluations that were undertaken as part of a continuing professional development (CPD) programme for health care professionals. The case is the SEARCH Program, an innovative CPD programme, which was designed to promote the implementation of evidence based practice (EBP) within the existing health care system in Alberta, Canada. Two approaches from the ‘using’ branch of Alkin and Chrisite’s evaluation theory tree are used in this research. The first employs a quantitative metaevaluation tool to retrospectively assess the quality of evaluations that were conducted from 2000 to 2005. The second is qualitative and explores the use of evaluations to inform programme development. The results of the quantitative analysis demonstrate that the evaluations scored poorly. In fact all evaluations failed to meet basic pass/fail criteria in three of the four standard categories. Reasons for this are explored and include the interdependence of criteria in the metaevaluation tool, the poor or incomplete quality of the reports and the retrospective nature of the process that did not allow for additional data collection. The apparent precision offered by the metaevaluation tool is questionable, as there is a lack of explanation regarding the weighting of the various items, the quantitative formulae used, and the criteria for classifying an evaluation as a failure. The tool is also limited by its focus on evaluation process with no consideration given to the results of the programme evaluations. The application of qualitative method was also time consuming but more fruitful. The results of the qualitative analysis demonstrate that the SEARCH Program was a complex, innovative and evolving programme functioning in a complex and changing health care system. Evaluation processes used within the programme were developmental in nature and informed substantive programme changes. The extent of the changes extend beyond what would be expected with standard formative or summative evaluation and fit with the concepts and use of developmental evaluation as articulated by Patton. The development of CPD programmes for health care professionals who are required to implement EBP is complex and requires collaboration between networks of professionals from institutions within health and higher education. Such programmes need to be reflective, innovative and flexible in nature due to the complex environments in which they are established and the complex outcomes that they wish to implement. This complexity and need for consistent re-evaluation of the goals of the programmes means that developmental evaluation may be an appropriate approach. It is acknowledged that developmental evaluation is difficult and requires both expertise and commitment of those involved. It is also acknowledged that such evaluation may be able to demonstrate immediate outcomes of the CPD programme for the participants and even the faculty but is much less likely to be able to demonstrate impact on the health care system in which it is used.