Effective medical consultations make an important contribution to positive outcomes for patients. For the large number of international doctors working in English speaking countries, deficits in language and communication skills can be a barrier to this effectiveness. This reflective report evaluates the effectiveness of 'Good practice' (McCullagh and Wright, 2008), a course book and related components, in addressing those deficits. The book filled a gap in the English for Medical Purposes literature, by providing learning materials with a clear focus on communicating in the doctor patient interview. Existing tools for evaluation which these materials can make to improving doctors' skills and knowledge.

Thesis Aim: Boundary violations are committed when a professional crosses the emotional, physical, spiritual or sexual limits of another, thus disrupting the relationship between staff and clients. This thesis explores this issue in the context of healthcare and forensic settings. It identifies boundary violation risk and protective factors for staff working with forensic healthcare patients. The thesis also investigates reasons why staff under-report and may not whistleblow their concerns in these areas. Methods: A mixed method approach was used to explore multiple elements of this topic. A systematic review was used to identify risk factors associated with staff committing boundary violations in healthcare and forensic settings. This was then expanded, through a regression, to specifically look at risk and protective factors in the forensic healthcare settings. A thematic analysis was carried out to explore staff’s perceptions of whistleblowing and boundary violating behaviours. A case study and several psychometrics (including the Exploitation Index) were also used to investigate this topic in more depth and assess the impact that boundary violating can have on the patients involved. Findings: The setting and environment were shown, through the systematic review, to be key when exploring this topic, as they not only impact on the definition of boundary violating along with what factors protect or put staff at risk of boundary violating. The regression identified risk factors, including staff feeling they had no one to turn to and working alone with patients. There were also factors which protected staff from committing boundary violations, such as having good social support and receiving training about boundaries. The thematic analysis found that people did not raise concerns of colleagues’ boundary violating due to concerns about anonymity, feeling that nothing would be done, and feeling that personally intervening (not management) would be a more effective method. Conclusions: It is of great importance to explore this topic and develop a greater understanding of boundary violations, as the impact of and harm caused by this behaviour are wide ranging. This thesis can aid the identification of professionals at risk, and create strategies to prevent or manage this destructive behaviour. These findings can also help create a more open and honest arena for concerns about boundaries to be raised and managed.

Background: The provision of high quality medical and surgical care is predicated by high quality education and training. This enables staff to respond more effectively and flexibly and is crucial when considering the various factors impacting upon the delivery of patient care. The development and training of all healthcare students and staff is an important factor in ensuring patient safety and self satisfaction, and relies on understanding the needs of learners as well as the way in which they learn. This fundamental training and education is no less pertinent in the perioperative environment, where high impact interventions are performed by Operating Department Practitioners (ODPs), and where patient safety and the quality of care must be paramount. This is due to the often difficult and potentially dangerous surgical and anaesthetic interventions on elective, unscheduled or critically ill patients. Aim: The aim of this programme of research was to investigate the effectiveness of ‘traditional’ lecture/placement provision in ODP education, resulting in the implementation and evaluation of a revised curriculum that integrates simulation based teaching and learning for this group of allied health professionals at the University of Portsmouth. Methods: This programme of research used a mixed methods QUAL + quant approach on multiple purposive and convenient samples of ODP students and placement education managers. Drawing on phenomenographic methodology, the interpretivist studies used semi-structured interviews and focus groups to investigate the understanding and perceptions of learning from those with relevant lived experiences. Furthermore, a positivist study was conducted to analyse and further understand the effectiveness of different teaching methods. The results from these studies informed a revision of the traditional ODP curriculum, based upon a nursing conceptual framework that included the integration of simulation-based learning. Results: A total of five studies were conducted, beginning with individual semi-structured interviews with 12, second year ODP students investigating perceived enablers and barriers to traditional learning using lectures in University and placement learning in the hospital environment. Study Two continued with a positivist study on a cohort of first year ODP students, which investigated the effectiveness of three types of teaching. The results of these first two studies informed a revision of the traditional ODP curriculum to integrate simulation-based learning. The revised curriculum was subsequently evaluated using focus group interviews and follow up interviews, with 30 first year ODP students. Finally, a focus group interview with 12 clinical educators that are responsible for the clinical placement learning for ODPs was conducted to gather their perceptions of the revised curriculum, and the clinical performance of the students. This led to the development of a conceptual framework to inform the integration of simulation-based learning into future ODP courses. Conclusions: The results of this research demonstrate that simulation-based learning for this professional group of ODP learners showed an encouraging trend in its effectiveness compared to other teaching methods. The revised curriculum encouraged higher order learning and mitigated to some extent the challenges faced by the NHS and placement educators. In addition, revising the ODP curriculum was evaluated positively by participants and clinical educators and tackled challenges such as inequity of learning opportunity and exposure to a diverse range of patient groups, that learners often face when undertaking learning on clinical placement. The conceptual framework designed to inform the curriculum identified specific areas for consideration when integrating simulation-based education into the ODP curriculum. However, further development and comparison of the conceptual framework reported here and a larger cross-university sample is needed to confirm its reliability and validity.

This thesis examines the transfer of an American pedagogical model to the Arabian Gulf against the wider context of the globalisation of higher education. Weill Cornell Medical College in Qatar is used as a case study to examine how American medical knowledge and professional practice are transmitted to and assimilated by an Arabic social setting. It considers the workings of what is presumed to be a universal pedagogical model by examining how the degree is culturally translated and localised in Qatar. It addresses the question of whether or not the Cornell degree of “Doctor of Medicine” is simply an American product transplanted to the Middle East, or rather a malleable artefact: sought out, manipulated and shaped by the Qataris for their own ends. Medical education necessitates a highly challenging process of acculturation that is amplified for Arabic-educated students who enter the American medical curriculum without many of the values derived from a Western educational system. In addition to language, students from Arabic-medium schools cite dress, familial, cultural and ethical dissonance as issues that had to be negotiated while undertaking the degree. Students enrolled at the American-style medical college currently divide their clinical training between the Gulf and America. The structure of the imported curriculum and biomedical practices generated in the metropole demand that students become bilingually competent in both Arab and American health care systems. The “American way” of doing things, however, does not always translate or conform to cultural mores and standard practice within the Gulf setting. This thesis follows Arab students as they move between the coeducational American academic setting and local health care facilities, examining the ways that the physicians-in-training contextualise, appropriate and reconstruct the medical degree according to their own cultural referential framework. The thesis introduces the language of “transplantation” as a heuristic tool through which the globalisation of higher education might be explored conceptually. It is an ethnography of an emergent educational transplant propagated in a globalised era, which explores novel modes of knowledge transfer, institutional and social arrangements across local and transnational boundaries, changing subjectivities and the generation of new life forms. In a setting in the Islamic world, Weill Cornell Medical College in Qatar provides a strategic site for observing the dynamics of a nation and its people grappling with modernity. Through its production of Americanstyle doctors in a non-American setting, Cornell’s transnational medical school serves as a niche through which to explore the tensions that arise in global models of tertiary education.

Patient feedback about practitioners’ and practices’ care is commonly used in UK general practice, sometimes by practitioner choice but often embedded in quality assurance and quality improvement programmes. Significant resources in NHS Scotland are spent gathering and reporting on patients’ reported experiences of care using a national GP patient experience survey – Better Together. There is however limited reference in current health policies to strong evidence demonstrating that this is an effective strategy to stimulate improvements in practice and patients’ experiences of care. This research study used realist review of existing literature to understand the impact of patient feedback at practice and practitioner level on patients’ experiences of general practice care, and realist evaluation of three general practices to understand how patient feedback is viewed and used for quality improvement in everyday general practice. Findings from the realist review indicate that there is little or no evidence that practice or practitioner level patient feedback leads to improvements in patients’ experiences of general practice care. The realist evaluation demonstrated great variance in how practice teams gather and respond to patient feedback and significant concerns about the validity of the Better Together survey. Variance in the strategies used to gather feedback and responses to it were predominantly influenced by collective staff beliefs about the quality of service they provided, their estimates of patients’ views of the service and their perceptions of patients’ preferences for providing feedback. While GPs mostly perceived that patients would be likely to tell someone in the practice when dissatisfied, interviews with patients indicated they had little understanding of how they could give feedback and an overall preference for doing this anonymously. One practice team was seen to initiate significant changes aimed at improving patients’ experiences but their ability to demonstrate improvements in experience were limited by changes in their workforce, conflicting externally set targets and methodological limitations of current patient experience measures. Further research is needed to understand how the findings from this study apply to general practice across Scotland and how practices can be best supported to use patient feedback to improve services.

The 1858 Medical Act removed geographical boundary restrictions on medical qualifications conferred in the United Kingdom, yet historians have hitherto overlooked this aspect of the legislation. This thesis uses practitioners working in London who held a Scottish qualification between 1861 and 1921 as a case study to consider the implications of this feature of the Act. It uses a database constructed using the Medical Directory and follows a prosopographical approach to examine the careers of these practitioners and identifies several defining characteristics that were a consequence of their training and qualifications. The central argument is that Scottish degrees and licences conferred certain opportunities and restrictions on their holders, which could assist practitioners in their careers or limit the work they undertook in the capital. However, these characteristics were not uniform across the entire group. There were differences between those who held a corporation's licence and a university degree, and the increasing number of women in the medical profession revealed a gender divide that diminished the relevance of holding specific qualifications for women. Furthermore, the introduction of panel practice under the 1911 National Health Insurance Act added an extra dimension to these distinctions. Panel doctors could acquire a practice from the government regardless of their qualifications, meaning they were less reliant on their own connections and networks. Additionally, the ongoing tensions between panel and non-panel doctors introduced new divisions into the profession that, in some respects, overshadowed previous boundaries.

While there is extensive research on medical doctors and their mental health, little is known about the specific barriers which prevent them from accessing psychological services. Numerous studies have shown that rather than asking for help from other professionals such as counselling psychologists and therapists, doctors would rather turn to drugs and alcohol to cope with their psychological distress. Junior Doctors (JDs) specifically are at particular risk of mental ill-health but feel prevented by their profession from seeking psychological treatment. Little research has been conducted on this particular subject area focusing specifically on JDs. This study readdresses the empirical evidence available for the issue and informs more clearly how counselling psychology and related professions can provide a more effective service to this client group. A constructivist grounded theory approach using eight participants allowed for a detailed examination of the participants’ subjective experiences of the research phenomenon and the generation of new theory on the barriers which prevent JDs from accessing psychological help. Of the eight participants, seven were from an Asian background and one was of Caucasian origin. Further, seven were male with the remaining one participant being female. A core category was uncovered from the analysis of the data which apply to the research participants: psychosocial barriers to accessing psychological services by JDs. This core category was informed by three main themes: 1) medical identity 2) the development of coping strategies in the British medical culture, and 3) the unacceptability of difference. This core category and its themes make up the grounded theory of the research. In light of the findings it may be suitable to adapt the usual process of therapy and negotiate a more appropriate method of delivering psychological support to reduce barriers and to promote credibility and effectiveness of counselling psychology among this client group.

The economic evaluation (EE) component of health technology assessments (HTA) often defines value in terms of health related quality of life, with many HTA agencies requiring the use of EQ-5D based Quality Adjusted Life Years (QALYs). These approaches do not capture value derived from patient experience factors and the process of care. This thesis widens the valuation space beyond this limited perspective, taking account of such factors, using monetary values generated from a discrete choice experiment (DCE), incorporating these into a discrete event simulation (DES) and conducting a cost-benefit analysis (CBA). The case study is monitoring individuals with ocular hypertension. Five strategies were compared using a DES: 'Treat All' at ocular hypertension diagnosis with minimal followup; Biennial monitoring (either in primary or secondary care) with treatment according to predicted glaucoma risk; and monitoring and treatment according to the UK National glaucoma guidance (either conservative or intensive). DCE based Willingness to pay (WTP) estimates for relevant health outcomes (e.g. risk of developing or progressing glaucoma and treatment side effects), patient experience factors (e.g. communication and understanding with the health care professional) and process of care (e.g. monitoring setting) were obtained. Conditional logit, mixed logit preference space and mixed logit WTP-space (rarely used within health economics) econometric specifications were used. These WTP valuations were aggregated in the DES, as fixed mean values or allowing variation between simulated individuals. While the standard cost-utility analysis (CUA) using EQ-5D implied 'Treat All' was most likely cost-effective, CBA with broadened valuation space identified, consistently across different econometric specifications, 'Biennial hospital' as the best choice. This thesis proposes an approach to broaden the valuation space that can be promptly used for EE-HTA. Researchers should be attentive of the valuation space considered in their EE and choose wisely the EE approach to be used (e.g. CUA and/or CBA).

The purpose of this thesis was threefold – First to investigate the emergence from the existing health system of nurse practitioners as a new occupation. Second to make sense of how nurse practitioners developed as primary care providers in the province of Ontario. Third to understand the nature and development of the intra-professional relationship between primary care nurse practitioners and physicians in local practice settings. I used a case study approach, with both historical (document review) and empirical (ethnography and interview) components. The empirical data was analyzed from an interpretive perspective using thematic analysis. A number of theoretical perspectives were drawn on, including Kingdon’s Agendas, Alternatives and Public Policy model, Abbott’s Occupational Jurisdiction model, Van de Ven et al’s Innovation Journey model, and Closure Theory. The study makes 3 contributions to new knowledge. First it documents the unfolding of events and actions over time, and thus serves as a historical summary. Second it adds an analysis of the case of nurse practitioners as an emergent occupation to the existing body of sociological analyses of professions. Third, it provides insight into how nurse practitioner - physician relationships are impacted at the local level because nurse practitioners are obligated to develop a relationship with a physician in order to be able to deliver comprehensive primary care services. The empirical component of the thesis analyzes and describes the nature of this relationship at a practice level. It also describes the use of ‘workarounds’ to bypass legislated restrictions in nurse practitioners’ scope of practice. It analyzes how structural differences in the manner of regulation, payment, and employment status between nurse practitioners and family physicians contribute to different styles of practice and perpetuate the hierarchical relationships between nurses and physicians. This knowledge has potential generalization to other emerging occupations, such as physician assistants and paramedics.

Migration has become an important feature of health labour markets due to the global shortage of health professionals. While there exists an extensive Labour Economics literature studying the general migration, policy development remains hampered by limited research undertaken in the health sector. This thesis fills some of that gap by examining the economic influences on and impacts of the migration of health professionals. The migration of skilled health professionals has exhibited strong sectoral properties, such as the motivation of career development and various regulatory regimes. We incorporate these features into the self-selection model by Borjas and Bratsberg (1996) and examine factors that influence the scale and skill composition of the migration flow. Our model suggests that the restrictive relicensing regime and work permit requirements for non-EEA professionals adopted by the British government to maintain practice standards and secure employment opportunities for native graduates, could only limit the migration from countries with higher returns to skills. The effect is ambiguous for most donor countries, which provide lower returns to skills.Using the administrative data derived from the Scottish dental system, we also examine the impacts of health professional migration within EU on the host country by investigating the performance of EEA dentists contracted under the Scottish NHS in terms of retention and treatment provision. A discrete-time survival analysis has been applied to characterize the time trend of the retention and identify factors associated with the likelihood of a dentist leaving the NHS. We also compare treatments provided by migrant and non-migrant dentists by estimating a difference-in-differences model. Unobserved heterogeneity in dentists is controlled using fixed effects.Our results suggest that EEA health professionals can be a good substitute to British graduates. They provide marginally different treatments and exhibit strong assimilation within two years post-entry. However, a constant issue we have found is their high turnover rates in the NHS: half of them left the service by the 26th month following entry. The primary policy recommendation of our analyses is that there is need for the government to develop recruitment initiatives so as to retain migrant dentists. Our results suggest hazards of leaving are significantly associated with dentists’ age-at-entry, arrival cohort and patient composition, but not with dentists’gender, country and practice deprivation. These findings potentially help to set evidence-based targets for international recruitment programmes