Feedback is consistently shown to be a key influence upon both achievement and performance. Feedback in medical education is not only important for the performance and progression of medical trainees but also for patient safety. However, despite recognition of the power of successful feedback, medical students within the United Kingdom and beyond consistently report dissatisfaction with the feedback they receive. Whilst the literature has begun to explore what students feel about feedback there is limited understanding of why they feel this way. Within this thesis are two distinct but related studies which combine to provide a synergistic picture of feedback at medical school. The first, a multi-school focus group study at three UK medical schools, explores students’ narratives of their lived experiences of positive and negative feedback. In exploring how students make sense of these experiences an in depth exploration is presented of not only what they think but also why. The second study presented in this thesis is a video-reflexive ethnography (VRE) study of feedback in two sites at medical school. This study comprises two phases: (1) an observational phase of data collection utilising video to capture feedback as it occurred in two sites at medical school (the simulated clinical skills setting and the medical workplace); and (2) the (reflexivity) phase of the study involving showing this footage back to student and tutor participants (separately) to explore their recognition and perception of feedback seen within the footage. In its totality, this VRE study allows for a comparison of student and tutor perspectives, as well as of feedback practices and perspectives in these two different sites. ii In summary, through listening to, and observing the lived experiences of feedback for medical students and their educators, the research presented within this thesis provides an in depth (and novel) understanding of both feedback practices and perceptions at medical school.

This thesis is concerned with the concept of undergraduate Interprofessional Education (IPE) as a possible model of practice for the education of health care professionals at the Faculty of Health Sciences, University of Malta. In 2010, the World Health Organisation published its Framework for Action on IPE and Collaborative Practice outlining a vision for a “collaborative practice-ready workforce” emphasising the importance of the health and educational systems as supporting pillars of IPE and collaborative practices (WHO, 2010, p.7). The concept of IPE had been mentioned in policy documents in Malta but no such model had ever been tried or tested at the University. This study aimed to explore stakeholders’ perspectives and perceptions of IPE and to encourage debate of adopting such an approach at the Faculty of Health Sciences. This thesis starts by tracing a history of IPE internationally, teasing out the diversity of policy drivers and motivating factors behind its inception and highlighting the lessons learnt for its development and sustainability into curricula; which, inter alia, include the importance of political drivers, national coherent policies, organisational support and earmarked central funding. This was crucial to underscore as it brought to the fore the paucity of such triggers for IPE within this research study. The study then adopts a qualitative case study approach underpinned by a social constructionist and interpretative stance designed to explore the possibility of IPE at the University of Malta. The purposive sample totalled sixty four participants and these included academics at the Faculty of Health Sciences, key informants from the education/health sectors and newly qualified health professionals. Data was gathered through a combination of focus group discussions and one-to-one interviews, and analysed using Ritchie and Spencer’s (1994) ‘Framework’ analysis supported by NVivo software. Findings yielded rich insights into participants’ perceptions of IPE; while they lauded the notion in principle, they identified a multiplicity of factors that would pose barriers to its enactment in practice. Some barriers might be described as symbolic while others were rooted in the practical domain of operational systems and structures. On a symbolic level, participants were particularly concerned that IPE would pose a threat to their professional identities and to the maintenance of boundaries that define the conceptual territories of the various professions. Participants also pointed to traits and behaviours they perceived as endemic in Maltese culture that would conflict with the enactment of IPE; these were especially relevant as the influence of macro cultural determinants has been largely overlooked in the interprofessional literature. These findings were interpreted through an interdisciplinary conceptual framework drawing on sociological discourses of professionalism and Bourdieu’s theories of societies and social practices. The framework also drew on concepts in anthropological discourses, focusing in particular on Hofstede’s theory of cultural dimensions as a means of theorising about the role that national culture can play in shaping perceptions and behaviours. The originality of this study lies in its a priori approach by exploring perceptions of an interprofessional model of practice when this philosophy had not yet been considered, and which in the process, identified contextual variables which could impact on the design and delivery of IPE. It is unique in employing various theoretical perspectives so as to transcend the factual findings and engage in higher order reconceptualisation. It is also the first study of IPE to be conducted in Malta; significant to consider for any potential interprofessional initiatives. This research contributes to the body of evidence underpinning IPE in two ways. It highlights again the existence of embedded hierarchies and power struggles across health systems and how these impact on IPE, and it uncovers the potential impact of national culture as a tangible determinant in the planning, development and delivery of IPE initiatives.

Diagnostic ability occupies a pre-eminent position in the skills of a doctor in modern society. Underpinning this attribute is a number of cognitive strategies which are gradually developed through a mixture of experience, acquired knowledge and training. These strategies include processing and structuring information, decision making, and the emergence of higher cognitive skills. The apprenticeship model in medicine assumes that students assimilate such skills during training, without ever questioning how they view or engage with the diagnostic role. The conceptual focus of this study is to use dimensional analysis (DA) to build theory from the perspective or ‘lens of the medical student’. This will use symbolic interactionism as its theoretical framework. DA acknowledges the relationship between the researcher‘s perspective and experience, the data and the participants using a constructivist, relativist epistemological philosophy. Filmed data has been analysed from real time simulated consultations between 3rd year medical students and a trained actor working from a standardised case (dyspepsia). Each participant completed a filmed consultation and a discussion of diagnostic ideas based upon the history alone. Diagnoses were re-evaluated in light of further examination data and the filming watched back with the researcher using a reflexive discussion approach. Nine participants completed the study providing a rich diet of interactive and reflective data from the simulations focussing upon diagnostic ideas. Emergent themes point to the central organising theory of intermediary cognitive adaptation during an important transition in the curriculum. This is characterised by the use of learnt cognitive strategies which act as failsafe mechanisms in maintaining process within the simulation. However, there are examples of naive cognition in applying aspects of conditional reasoning and interpreting clinical probability rules. The diagnostic process is driven by the clinical history with little integration of the physical examination features. This finding may explain the emergence of cognitive errors during undergraduate training, and links normative theory with diagnostic errors seen in clinical practice. Reconstruction of clinical skills and diagnostic thought through reflective analysis are evident. Under the right conditions, simulations can provoke a constructive (intrinsic) perspective on cognitive skills which can advance professional development in the diagnostic reasoning process.

This study examines the benefits of learning innovations in e-learning (asynchronous classrooms only) and blended learning (asynchronous virtual classrooms plus traditional learning) compared to traditional learning (classroom lectures). It specifically investigates effects on student satisfaction, retention, progression and achievement. We focussed on core biomedical science modules at London Metropolitan University: and four such modules were electronically supported using a learning and content management system programme. The collaborative learning intervention (N = 193, 71 males, 122 females), showed there was no significant change observed in performance across pre-intervention and post intervention modules over five years, with the exception of the 2010 cohort (p = 0.008) where students responded positively to the intervention. Interestingly, the quality of student online posts and final group grade for coursework revealed a strong positive relationship (r = +0.69, p < 0.0001, 42% improvement). We determined that tutors enhance work quality via moderation of online posts. The availability of personalised, timely and iterative feedback is likely to be responsible for this difference. Gender differences were apparent. There was a strong positive correlation between overall group rating and individual rating in male students only (r = +0.81**, p < 0.0001, 65% of predictions correct) and with males’ personal expectation (r = +0.5**, p < 0.0001) (Table 4.4). Males’ mean self-rating was 9/9 and females 7.9/9. Interestingly, 52% of females were likely to predict their final grade accurately, appearing to base this judgement on their interaction with the work and results self and peer assessment. The judgement of male students appeared to be based solely on self-belief that out stripped attainment with correct predictions in 25% of cases. The mean coursework pass mark for the post intervention module increased compared to previous years. Student self-evaluation showed that >80% enjoyed the collaborative learning work elements. For an optional formative assessment intervention, impact was evaluated over five-years. This study identified a significant difference between the intervention cohorts and the non-intervention year group, who were educated traditionally. When the post intervention groups were compared to the control, highly significant p values were obtained (p = < 0.0001 to < 0.00001). Additionally, students who were ‘quiz avoiders’ attained lower grades. The control group (N = 190), attained a mean mark of 55.3%, within this group, quiz avoiders achieved marks ranging from 34.4-42.6%. Quiz takers performed better than the control group with the mean marks ranging from 59.2-61.2%. Thus, blended learners’ achievements significantly improved (p = 0.0001), compared with those pre-intervention and those not engaging. In terms of self-evaluation, 60% of students rated the formative assessment (online quizzes) as ‘useful’ or ‘very useful’. Web-based collaboration improved academic performance and student satisfaction. Comparisons between pre-intervention and intervention groups were significantly different to the fraction of final exam first sit passes (p = 0.048). The intervention group showed the improvement. Interventions were applied at specific time points so that intra-annual comparisons could be drawn. This study detected profound differences: the mid-year exam (pre-intervention) was compared to the final exam (post-intervention) and showed a significant first sit performance (p = < 0.0001). Interestingly, 70% of students stated they would like the intervention (BB Collaborate) in more of their modules. We have shown, for the first time, that longitudinal studies over five year of large cohorts, there is a consistent significant improvement in student performance and engagement-using reward based formative assessment (Jacoby, et al., 2013 – incorporates data from this thesis). These interventions have subsequently been incorporated into the successful London Metropolitan University biomedical science course and in combination led to enhanced retention, progression and achievement over the study period. Furthermore, the practices illustrated are applicable to a modern higher education environment and are likely to enhance many similar course routes across the sector.

This thesis lifts the lid' on the educational practices within a medical education programme, which is based upon a Problem-Based learning (PBl) approach. It is an ethnographic case study that sets out to understand the practice and facilitation of PBl situated within a hybrid curriculum at a graduate-entry medical programme in England. Data was collected by audio-visual recording of PBl sessions, audio recording and observing facilitator meetings and through the author's experiences as a participant observer working as a facilitator within the research setting. The study exposes a variety of PBl practices within a single curriculum setting that have not previously been examined in detail within medical education, in particular through use of direct observational methods. The findings pose a challenge to a core educational objective, upon which the 'PBl' programme was founded, that being to develop students' skills as self-directed learners. While this is highlighted within the literature as a central component to the PBl process, the findings raise questions about how these assumptions are reflected in the practice of PBL.

The premise for this research initially stemmed from a perceived crisis facing the provision of the nuclear medicine service within the United Kingdom, the possible impact posed by the shortage of nuclear medicine clinicians and the untapped potential of a body of non-medical healthcare practitioners working within the nuclear medicine sector to whom recognised additional roles, such as reporting of images, may sensibly be delegated. Yet, despite the support by various professional bodies and colleges, uptake is not widespread and appears to be ill provided for in terms of educational programmes. From an educational perspective, with ever advancing technology and the ubiquity of web based resources, eLearning within healthcare is still in its infancy. Certainly its ability and flexibility to reach geographically diverse populations of learners, is undisputed, yet whilst advantageous to the professional leaner in accessing material away from a restricted campus based environment, its efficacy to teach a skill, or competence, and indeed to translate this to clinical practice remains largely unproven. With both these issue in mind, the project question was posed as to whether it was possible to establish the efficacy and credibility of an eLearning resource to prepare and support the training of non-medical healthcare practitioners working within the field of nuclear medicine in reporting of bone scans.

This thesis explores the way General Practice trainees and early career General Practitioners describe their training environment in General Practice, the meaning they attach to the notion of preparedness and their perceptions of the impact of the training environment on their preparedness. The study was informed by the interpretivist paradigm. I conducted 27 in-depth semi-structured interviews with 15 early career General Practitioners and 12 General Practice trainees at the end of their training. Interview data were transcribed and analysed thematically, drawing partially on the grounded theory approach of data analysis. Interviewees described their training environment in terms of their sense of being included in the Practice, the Practice ethos, the importance of training within the Practice, the trainer and their relationship with the trainer. There was no unanimous way in which interviewees talked about preparedness, however the meanings attributed to preparedness centred around two central elements ‘confidence’ and ‘adaptability’ and included: working independently and being self directed; knowledge of business and partnership issues; ability to manage patients and workload; good consultation skills and effective time management; and adequate knowledge and passing the RCGP CSA examination. The way the training Practice can impact on trainees’ preparedness was explained drawing on Bandura’s theory of ‘self efficacy’ and Lave and Wenger’s theory of ‘situated learning’. Inclusive training Practices, characterised by less hierarchical relationships between the doctors, particularly vis-à-vis trainees, were better at preparing trainees for their future role by affording them greater opportunities to take part in a wider range of General Practice work. The role of the trainer was also pivotal in preparing trainees through effective teaching. Supervision tailored to trainees’ needs, and guided decision making enhanced confidence of trainees in their ability to work independently.

The complexity of healthcare is increasing due to new discoveries in the treatment of disease, the multiple pathologies of an ageing population and changes in working patterns and job roles. In addition, an increase in professional, regulatory and public scrutiny has led to revelations of poor care leading to preventable disability and death. Inquiries into sub-standard care have uncovered a number of professional lapses, in particular failures in teamwork and leadership. Medical undergraduates are future doctors. Their ability to work effectively within teams and to lead when necessary will therefore have a significant impact on the health of the population. In order to improve leadership and teamwork abilities we must be able to assess them. A literature review searching for a tool to assess teamwork and leadership in the medical undergraduate was carried out. As a consequence of an unsuccessful search, a tool was developed and evaluated, using data from existing tools and from a series of focus groups with medical undergraduates. The focus groups and an examination of the reasoning of assessment participants also informed a study on the justifications for failing to challenge poor performance by a more senior member of staff. The tool data showed adequate validity and reliability for formative assessments in a simulated environment. The focus groups and examination of reasoning highlighted the continued existence of the medical hierarchy, with steep authority gradients. This tool can be used in formative assessments, but further research is required before it is used outside the simulated environment and consideration must be given to psychometrics, feasibility and cost. The teaching and assessment of teamwork and leadership, should be given more time in the undergraduate curriculum and medical schools, regulatory bodies, deaneries and trusts should collaborate on minimising the unprofessional behaviours of senior healthcare personnel.

Objectives: The management of depression and anxiety in primary care in the UK is not consistent with clinical guidelines. This has led to training initiatives that aim to change practice by improving the implementation of research evidence, but little is known about what constitutes effective healthcare professional training in this area. This thesis addressed this issue by identifying what determines effective training to improve the management of psychological distress in primary care. Methods: The research was undertaken in three stages. A systematic review and narrative synthesis was conducted to investigate the effects of controlled trials of training interventions delivered to primary care practitioners (PCPs) to improve the management of psychological distress on process outcomes (practitioner behaviour, knowledge, attitudes). Then two qualitative studies using semi structured interviews with PCPs (n=18) and experts in training/behaviour change (n=16) were conducted to explore their perceptions of effective healthcare professional training in this area and in general. The qualitative data were synthesised to produce recommendations for designing effective healthcare professional training to improve the primary care management of psychological distress. The research findings were used to develop a taxonomy of training intervention components for use in the design and reporting of healthcare professional training interventions in this area and more widely. Results: Forty Papers (36 studies) were included in the systematic review. The papers reviewed provide a mixed picture of the effective characteristics of training interventions. Two components: the inclusion of skills practice (role-play) and the use of theory to inform intervention content were associated with positive outcomes. Limitations with outcome measures, absence of theory and poor descriptions of the interventions made it difficult to determine effective intervention components. The analysis of the qualitative studies resulted in the development of the Perceived Effectiveness of Training (PET) framework. It incorporates five themes or core areas that underpin effective training: social interaction, credibility, relevance, information processing, and practicalities. The PET framework was used to identify effective training intervention components. Finally, the qualitative synthesis led to the development of a taxonomy of training intervention components, which was evaluated for comprehensiveness by mapping the training components to the interventions identified in the systematic review. This culminated in a 171 item taxonomy with hierarchical groupings divided into three phases: pre-training, training delivery and post training. Conclusions: Healthcare professional training to improve the management of psychological distress in primary care can be optimised for effectiveness using the PET framework to address core quality training standards. It is recommended that the taxonomy of training intervention components should be used to improve the science of healthcare professional training interventions. Further research to develop the taxonomy and to establish valid training evaluation measures would provide further scope to identify which training components can predict healthcare professional behaviour change and improve the management of psychological distress in primary care.

Background: Whilst direct-observation, workplace-based (or performance) assessments, sit at the conceptual epitome of assessment within medical education, their overall utility is limited by high-inter-assessor score variability. We conceptualised this issue as one of problematic judgements by assessors. Existing literature and evidence about judgements within performance appraisal and impression formation, as well as the small evolving literature on raters’ cognition within medical education, provided the theoretical context to study assessor’s judgement processes.Methods and Results: In this thesis we present three studies. The first study adopted an exploratory approach to studying assessors’ judgements in direct observation performance assessments, by asking assessors to describe their thoughts whilst assessing standard videoed performances by junior doctors. Comments and follow up interviews were analysed qualitatively using grounded theory principles. Results showed that assessors attributed different levels of salience to different aspects of performances, understood criteria differently (often comparing performance against other trainees) and expressed their judgements in unique narrative language. Consequently assessors’ judgements were comparatively idiosyncratic, or unique.The two subsequent follow up studies used experimental, internet based, experimental designs to further investigate the comparative judgements demonstrated in study 1. In study 2, participants were primed with either good or poor performances prior to watching intermediate (borderline) performances. In study 3 a similar design was employed but participants watched identical performances in either increasing or decreasing levels of proficiency. Collectively, the results of these two studies showed that recent experiences influenced assessors’ judgements, repeatedly showing a contrast effect (performances were scored unduly differently from earlier performances). These effects were greater than participants’ consistent tendency to be either lenient or stringent and occurred at multiple levels of performance. The effect appeared to be robust despite our attempting to reduce participants’ reliance on the immediate context. Moreover, assessors appeared to lack insight into the effect on their judgements.Discussion: Collectively, these results indicate that assessors score variations can be substantially explained by idiosyncrasy in cognitive representations of the judgement task, and susceptibility to contrast effects through comparative judgements. Moreover, assessors appear to be incapable of judging in absolute terms, instead judging normatively. These findings have important implications for theory and practice and suggest numerous further lines of research.