Nurse mentors are crucial in ensuring that only students who are competent and fit for practice enter onto the professional nursing register in the UK. However, the literature continues to reflect a perception that mentors are reluctant to fail student nurses in practice. There is minimal research focussing on mentors who do fail, and even fewer studies focussing on the mentor experience of failure in the final placement. An interpretive, hermeneutic phenomenological study, guided by the philosophy of Gadamer (2004), was carried out to explore, interpret and develop an understanding of mentors‘ experiences of failing pre-registration nursing students in their final placement. Nineteen mentors from seven different organisations were interviewed and guided through a process of reflection on their experience; these were then transcribed to form a text. A hermeneutic textual interpretation revealed four horizons (Gadamer, 2004) that united the mentor experience. Mentor expectations of being fit for practice‘ included the meanings they attached to their role, which was in a metaphorical sense to polish the rough diamond‘, and the meaning of being the whole package‘ in order to be deemed fit for practice. Their reflections revealed the consequences of failure‘ which includes the meanings of a failure to act and challenge‘ students, and the personal price‘ they had to pay in making the decision to fail. The act of failing in the final placement‘ explicates the meanings of an unavoidable subjective dimension‘ to the decision, and the perceived barriers and enablers‘ of making the decision to fail which include workload and time‘, and perceived attitudes towards the mentorship role‘. The horizon of self realisation‘ illuminates the meanings of a sense of professional responsibility and accountability‘, and personal growth and enlightenment‘. Through a hermeneutic process of interpretation, this thesis uncovers an understanding of being‘ a mentor who fails a pre-registration nursing student in their final placement. This understanding reveals new possibilities for mentors, educators, policy makers and researchers.

This thesis examines, from a sociological perspective, the careers of doctors from a developing country without its own medical school or strongly organised medical profession. It argues that the interplay between the socio-economic and political forces and doctors' experiences internalised over the years at medical school, contribute to medical migration in Botswana from the public sector to private practice, and abroad. First, the thesis examines the influences that come into play when Botswana citizens choose a medical career. Then, the study explores students' medical school socialisation outside Botswana, and how this interfaces with subsequent workplace experience in Botswana. The retention efforts within the public health service and the 'pull' factors to the industrialised nations and international agencies are also studied. Data collection for this study was mainly through in-depth interviews with citizen doctors in the public and private sectors in Botswana. For doctors abroad, computer assisted interviewing was utilised. The data reveal that, in choosing a career in medicine, doctors came under varied and sometimes conflicting influences, at the family, community and institutional levels. While studying abroad, doctors were exposed to the modem technologies and facilities and an environment perceived as being conducive to work and study at the same time. These come to be pull factors when doctors, thus trained and socialised, wish to apply their skills and knowledge in practice on their return home. What obtains in medical practice, and the expectations from the state and the public for the medical profession are different from those the doctors have been socialised to expect. This situation leads to complaints and resignations by doctors. In themselves, such complaints are not peculiar to Botswana, but Batswana doctors are relatively well placed to leave the public sector. The study suggests that the solutions devised to address doctors' concerns should go beyond tinkering with monetary incentives

Background Health care professionals are responsible for maintaining their proficiency throughout their careers. Continuing medical education (CME) is an integral part of the medical profession that aims to enhance physicians’ knowledge and skills. Health care services in Saudi Arabia are expanding rapidly. However, the country is struggling to cope with a shortage of competent health professionals. CME in the Kingdom is facing some challenges that are preventing learning programmes from responding appropriately to professionals’ demands and needs, and to the complexity of health care. Research questions The research questions addressed in this thesis are: 1. What is the current status of continuing medical education in Saudi Arabian governmental hospitals? 2. What are the barriers preventing continuing medical education from implementing competitive learning programmes? 3. How might Saudi culture be influencing the health context and how does this impact upon the field of CME? Methodology This study adopted a mixed methods approach supplemented by ethnography. Two forms of individual, semi-structured interviews targeted two groups of respondents; the interviews were followed up by a questionnaire (sent by email) listing all the challenges to CME identified by the interviewees, and asking the participants to rank them in order of importance. In addition, observation was conducted throughout the fieldwork. Sampling Three public hospitals were selected from different geographical areas (N=3). Judgemental approach resulted in the selection of 33 medical education representatives from different medical and paramedical departments (N=33). Purposive sampling resulted in the selection of 11 medical librarians (N=11). Results The major CME challenges were identified and grouped into four themes: 1. Management, including the lack of knowledge on the part of decision makers about the importance of lifelong learning, and their influence over learning programmes. 2. Poor status of medical libraries, in terms of location, space and services provided. 3. Lack of transparency in the CME budget, which leads to a too close relationship between the pharmaceutical industry and physicians. 4. Diversity of staff, including their different training backgrounds, and their resistance to making changes in their performance after training. Discussion and conclusions The study found a strong correlation between health stakeholders’ lack of managerial skills and knowledge of the significance of CME and the learning programme limitations in Saudi Arabia; this factor also received the highest ranking by the participants in the study. 3 Hospital officials lack the necessary knowledge about the importance of CME, and lifelong learning has become complex. Their negative attitude towards learning has resulted in several challenges: some of these have been identified in this study, including a lack of support for the learning process in hospitals, an inability to motivate staff to continue developing their skills, and a lack of transparency when allocating budgets to learning elements, including CME and library services. This ambiguity has resulted in poor libraries and a heavy reliance on pharmaceutical industry sponsorship for CME events and medical professionals’ trips, which can affect the quality of the events and/or cause bias. The study has also clarified the issue of staff diversity. Although the majority of health care professionals are foreigners, the concern is that health care stakeholders are recruiting professionals from developing countries where the quality of health care and training might be low. Despite the varied training and educational backgrounds among the staff, no efforts have been made to design learning programmes that meet their actual and wide-ranging needs. Rather, current activities are based on desires and wishes of chiefs of medical departments.

General practitioners must be able to respond appropriately to the full range of medical conditions that present to them during their surgeries. To do this they require adequate training in a variety of specialties. Concerns have been raised regarding general practitioners training in certain areas. One of these is the management of musculoskeletal conditions. The overall aim of this study was to explore the musculoskeletal learning needs of trainee general practitioners by identifying the conditions they see during their day to day work and then asking them to reflect on these. A secondary aim was to create an educational package focused on one area of learning need and to evaluate this. A questionnaire study initially performed in 1995, which highlighted concerns regarding training in this area, was repeated to see if the situation had changed. Thereafter thirteen trainees kept a diary documenting all of their musculoskeletal consultations for a month. They were also asked to document any perceived learning needs regarding these consultations. The trainees were then interviewed and their identified learning needs were further explored. Any others learning needs in musculoskeletal medicine were also discussed. Focus groups with a further two groups of registrars were performed, along with interviews with eight trainers, in order to triangulate the data and to explore their ideas. An educational package on the management of shoulder pain, one of the areas identified by the trainees, was developed and trialled with a different group of doctors by using a pre- and post- knowledge test. Confidence in managing musculoskeletal disorders in doctors currently training for a career in general practice remains poor. Learning needs were identified in a variety of different areas. It is possible to create an educational package focused on a specific area which can address these needs.

Healthcare within the UK is undergoing a transformation in terms of traditional role and skill assignations of staff, with an attendant blurring of boundaries seen in terms of the practice of skill in many clinical settings. This has implications for the development and future learning of the staff involved and the aim of this study is to explore how feedback from a supervisor is used to develop and sustain skill in a group of nurses and, in this way, examine the interaction between the learner, the supervisor and the context in which the learning is set. This thesis uses a social constructivist stance and a mixed method approach to answer research questions set. 85 nurses were invited to undertake a web-based questionnaire and semi-structured interviews were conducted on ten of the respondents. The themes which emerged were: developing identity and fitting in; mining tacit knowledge and managing ambiguity; support versus dependency; and, finally, the development of judgement. The study reveals a group who learn in a context that they find enjoyable and is often conducive to learning. The participants are well motivated to learn and they have access to the skills and knowledge of experts. However, learning is also seen to be dominated by the context in which it is set and as the participants learn motor skills, they also learn to fit in and manage a brittle working environment. This thesis illustrates an aspirational professional group for whom the governance of learning leads the participants to be confident to seek help. The thesis concludes by suggesting changes to the pedagogical model employed and avenues for further research.

Judging the quality of reflective portfolios is assuming critical importance with their increasing use in accreditation and revalidation. The experience of this work has shown that despite explicit instructions to compilers, considerable investment in assessor training, and the negotiation, agreement and publication of overt criteria, individual assessments are consistent but show only fair inter-rater reliability and are untrustworthy in high stakes assessment. This study has also shown that reliability is not improved through the process of trying to 'shape' portfolios to introduce structural consistency, although it can be improved by using discussant pairs of assessors, with consequent issues of cost. While this method should be further researched as a means by which portfolios can be judged, consideration of the nature of professional practice and the processes that underpin judgements made by professionals moves the debate towards rejecting the traditional first hurdle of reliability before examining the validity of assessment tools. This thesis describes a methodology that begins the process by justifying the general direction such enquiries might be taking. Based on an exploration of the issues, it offers a model for a system for the assessment of professionals that is both theoretically supported and practically possible.

Research in the medical careers field in the UK tends to concentrate on career destinations for doctors and is used as an input into workforce planning by the Department of Health. Changes to medical career pathways, introduced by the Modernising Medical Careers programme, have brought into focus the need for medical schools and postgraduate deaneries to provide career support to medical students and postgraduate doctors. This study considers the practical aspects of how coaching can support these doctors to make career choices. The research is a qualitative case study that considers medical careers within a medical education context. Interviews were carried out with 13 coaches; five clients were either interviewed or asked to complete a qualitative questionnaire, and I kept my own reflexive diary. Thematic analysis was used to develop the findings from the research. Four key areas were identified in the data: what doctors bring to coaching, what coaches need to work with doctors, the coaches’ approaches to coaching, and the coaching conversation. They have been combined into a framework that can be used by coaches, and also by trainers and supervisors who work with postgraduate doctors. From a wider perspective, career coaching seems to encompass the aims of career support as well as go beyond it into other aspects of doctor’s lives, such as work–life balance. Additionally, coaches used stories and metaphors in their work: one metaphor described doctors as being surrounded by the ‘medical bubble’. The issues of the coaches’ expertise and self-disclosure in coaching are discussed. Trainers and supervisors who provide career support may wish to consider their own development needs.

The field of medical education is an ever evolving area constantly enriched by newly discovered information and changing facts provided by active research in all areas of medicine. The recent years have witnessed the introduction of a number of promising technologies and applications to medical education to meet this demand. Virtual Reality (VR) applications are considered one of the evolving methods that have contributed to enhancing medical education. This Thesis utilises Virtual Reality to provide a solution to improve the delivery of the subject of anatomy to medical students, and facilitate the teaching process by providing a useful aid to lecturers, whilst proving the effectiveness of this new technology in this particular area. An intensive investigation into the current anatomy teaching system in the Faculty of Medicine in the University of Jordan was carried out and the challenges this system faces were characterised. The lecturers and students needs and requirements were identified, and measured against the perceived training system adapting the SERVQUAL instrument, and limitations associated with current teaching modalities were defined. In order to overcome these limitations and enhance the anatomy education process, a novel system was developed utilising VR technology. This system offers a real-time 3D representation of the heart in an interactive VR environment that provides self-directed learning and assessment tools through a variety of interfaces and functionalities. The effectiveness of VR technology and the usefulness of the developed system in improving the understanding of the anatomical structures were proven through a randomised controlled study. In order to assure future utilisation of the system by teaching staff and students in the Faculty of Medicine, further evaluation was conducted adapting the Technology Acceptance Model. This confirmed the end users' acceptance of the system as a teaching and learning aid, and their intention to incorporate it into the anatomy education process in the future.

The Medical School of the University of Liverpool is at a critical phase in its development. Through the 1990’s and 2000’s it improved from being at the bottom of the league tables, with graduates who were imperfectly prepared for their pre-registration house officer posts, to being at the top of the league tables with the best prepared graduates. In more recent years it has performed badly in the National Student Survey, and has, consequently fallen down towards the bottom of the league tables. The graduates are still well prepared, but the sense of cohesion and common endeavor within the medical school has been lost. This is manifest in several ways, but the trigger for this study was a difficulty in recruiting senior clinicians to teach our medical students. A series of semi-structured interviews was held with a purposive and convenience sample of fourteen senior clinicians. Nine of the participants were members of full time University staff with honorary National Health Service (NHS) contracts, and five were full time NHS clinicians with honorary University contracts. The gender balance was equivalent to that of the senior clinicians in our region (60M:40F). The approach taken in this study is a critical realist approach, whereby it is recognized that individual participants experience and interpret reality in their own particular ways. The factors that individuals consider to facilitate or frustrate their involvement in teaching undergraduate medical students are, at best, a proxy measure for the actual constraints and enablers. The themes extracted from the interviews were studied using a constructivist grounded theory method. The major enablers for being involved with teaching undergraduate medical students were the students themselves, and a desire to give them the best possible experience. The major constraints were a lack of clarity about expectations, a lack of recognition for those involved in teaching, and the difficulty of balancing competing imperatives. The two new elements uncovered in this study are the influence of colleagues (for good or ill) and the relative unimportance of “time” itself. A series of recommendations are made which involve leadership, communication, recognition, and, crucially, ensuring the agency of those who wish to be involved in educating undergraduate medical students. Awareness of these issues should strengthen the medical school in its resolve to improve the student experience, and rebuild our community of practice.

Medical education in the UK is regulated by the General Medical Council (GMC), which among other things, formulates and publishes policies to effect this regulation. The latest GMC policy on medical education was published in July 2015 and came into effect on 1st January 2016. As educational organisations and educators endeavour to implement the latest GMC policy therefore, I contend that it is both fitting and germane to seek to provide a critical understanding of the policy by analysing its heritage, ramifications and significance. The literature on policy studies in medical education, and engagement with policy by medical education organisations and educators are meagre, in spite of the abundance of policy covering this area. This work presents a post-structural critical policy analysis of the 2015 GMC policy, in the light of its preceding policies published in 1993, 2003, and 2009. It uses documentary evidence and applies the study of problematisation in and of policy to the discursive representation of policy problems, evaluating how these have evolved and transformed in light of the prevailing sociopolitical contexts, and critically analysing and reflecting on the implications and significance of these problem representations. It finds that the GMC policies hinge on the problematisation of medical education as an issue of patient safety, educational prerequisites and the workforce demands of an increasingly decentralised and marketised health service. It argues that this problematisation is situated in notions of individual responsibility, marketisation and social accountability, and is underpinned by a reliance on the asymmetrical union of neoliberal and socialist ideologies. The findings might be particularly useful to medical educators and educational organisations who have an interest in contributing to the development of further medical education policy. This work will contribute to the body of policy studies and medical education literature and, it is hoped, stimulate further research into medical education policy.