This thesis explores the relationship between physicians’ clinical and educational roles in the context of UK General Practice (GP) education by investigating the experiences of seven GP trainers through an ethnographic approach employing Activity Theory (AT). The Introduction considers the philosophy and structures of GP education and outlines the author’s professional biography to provide context. The Literature Review focusses on the development of medical education as a discrete field and identity formation in medical educators, concluding that: specialist medical educators are a relatively new group; and there is a paucity of knowledge regarding the impact on physicians of occupying dual clinical and educational roles. The thesis then focusses on three Research Questions (RQs), namely: 1. What is the impact of GP trainers’ clinical practice upon their educational work? 2. How does GP trainers’ educational practice influence their clinical work? 3. What are the social contexts for GP trainers’ clinical and educational practice? These questions are addressed within a pragmatic theoretical framework to build up an ethnographic description of the participants’ experiences. Data collection is through semi-structured interviews and observation of video-recorded teaching. Ethical issues associated with the study are discussed in detail, in particular the challenges of “insider” research. Four approaches are used for data analysis: global impressions; word cloud analysis; thematic analysis; and analysis shaped by AT. In answer to RQs 1 and 2, the study finds that GP trainers experience their dual roles as intimately linked, intuitively transferring their skills between their clinical and educational practice. The study also finds that GP trainers reconstruct their professional identities through teaching. With regard to RQ 3, engaging in teaching can lead to internal conflict for GP trainers and tensions with their colleagues, trainees and regulators. These findings are discussed in relation to medical education research methodology and the impact the study on the researcher is explored. The thesis closes by considering the conflicted position the participants occupy, concluding that teaching offers physicians the opportunity to reconstruct their professional identities so they can approach tensions in their practice with a sense of agency and optimism.

The General Medical Council now requires that all new medical graduates in the United Kingdom should be able to ‘function effectively as a teacher’. This thesis explores multiple perspectives on what this means, and the implications for medical student learning in relation to teaching. There is a lack of existing literature exploring how those involved in the undergraduate medical curriculum conceptualise teaching or what it means to function effectively as a teacher. There is also a lack of literature on what teaching recent medical graduates undertake, and what, if any, learning outcomes in teaching they and other key stakeholders think should be core for the undergraduate medical curriculum. To address these gaps in the literature, original data were gathered using 1) a Delphi study with eighteen experts in medical education, 2) semi-structured interviews with nineteen recent medical graduates, and 3) focus group interviews with twelve final year medical students. The three data sets were analysed individually, compared, then synthesised with the existing literature. All three participant groups articulated a wide range of conceptions of teaching, with considerable variation both within and between groups. The great majority thought that all medical students should learn about teaching as part of the undergraduate medical curriculum. Almost all of the recent graduates and medical students viewed teaching as part of the role of junior doctors working in the UK, although only two thirds of the recent graduates said they saw themselves as teachers. The recent graduates reported having delivered a wide range of teaching in their first year of work as junior doctors, and this correlated well with the range of teaching medical students reported having received from junior doctors. Teaching undertaken by recent medical graduates could be grouped into three broad categories: informal opportunistic teaching, semi-formal pre-arranged teaching, and formal organised teaching. A total of 153 learning outcomes in teaching were suggested and rated by the expert Delphi panel in terms of how appropriate they were for UK undergraduate medical curricula. Many of the graduates and students also suggested some learning outcomes in teaching before rating the 153 learning outcomes arising from the Delphi. All three groups indicated that they thought most of the 153 learning outcomes in teaching should be core for all UK undergraduate medical curricula, although there was some variation within and between groups. The majority of these learning outcomes have not been previously suggested in the literature for UK undergraduate medical curricula, but are consistent with literature on teaching competencies expected of more senior doctors. This thesis offers new insights on what teaching means to experts in medical education, recent medical graduates and current students, comparing these between groups and with the educational literature. It also offers multiple perspectives on core learning outcomes in teaching for UK undergraduate medical curricula, and greater understanding of the teaching undertaken by UK medical graduates. This thesis could help those responsible for undergraduate medical curricula to prioritise, refine and exemplify detailed learning outcomes in teaching, ensuring their graduates are more prepared for practice. It will also be of interest to policy-makers, programme directors, teachers, students, junior doctors, administrators and academics involved in medical and allied healthcare education. It is hoped that this thesis will encourage stakeholders to reflect on what teaching means to them, the role of junior doctors as teachers and the implications of learning about teaching as part of the undergraduate medical curriculum, leading to greater engagement, scholarly debate and research in this area. This in turn may lead to doctors delivering better quality teaching, to students and trainees in medicine and other disciplines receiving better teaching, and consequently to patients experiencing better healthcare.

No description available.

The focus of the research programme within this thesis is an investigation of scenario-based simulation training in undergraduate healthcare education. The aim of the main study was to determine the effectiveness of high-fidelity simulation training with adult branch nursing students. Their acquisition of knowledge and skills was tested using a 15-station Objective Structured Clinical Examination (OSCE) pre- and post- the simulation intervention with randomised control and experimental groups of volunteer students. The results show that simulation training is an effective learning method as students from the experimental group, who were given the opportunity to observe and take part in high-fidelity simulation training followed by debriefing, made significantly higher improvements between their two OSCE performances than students from the control group. The second study focused on interprofessional learning with a randomised control group investigation of the students’ knowledge of the roles and skills of other healthcare professions involved in the same simulation session. The results demonstrate that observing and taking part in multidisciplinary scenarios and their debriefings contributed to the students’ acquisition of knowledge about the roles and skills of other health professionals. The study also showed that students’ perception of multidisciplinary team working was significantly influenced by whether or not they had experienced interprofessional high-fidelity scenario-based simulation training. The main original themes emerging from the research work presented in this thesis comprise the implementation of high-fidelity scenario-based simulation training and debriefing with undergraduate students from a range of healthcare disciplines and the objective measure of the effectiveness of such learning opportunities. This work has now started to impact on simulation practice in undergraduate education within the University and beyond

Recognising Acute Deterioration: Active Response (RADAR) is a simulation based teaching session using simulated patients to portray acutely unwell adult hospital patients. The genesis, development and progress of RADAR will be discussed along with the findings of questionnaires and focus groups from two further cycles of action research. Readers will become aware of the impact which RADAR makes to the evidence and learning surrounding the recognition and assessment of clinical deterioration in adult hospital patients. The study investigated the impact of simulation on medical students’ confidence in recognising and responding to clinical deterioration in adult hospital patients using simulation, simulated patients and moulage (make-up).

Due to increasing societal demands, accountability and economic constraints, there has been a paradigm shift in the healthcare culture with a move to formally train medical educators. This has resulted in the professionalisation of medical education, with various development initiatives including postgraduate qualifications. The demand for these qualifications in medical education can be judged by the increase in providers, from 2 to 31 in the UK and from 7 to 124 worldwide over the last two decades. However, detailed information about the influence and effectiveness of such courses remains sparse. This study investigated the impact of postgraduate qualifications in medical education on graduates’ educational identities, practices and career progression. The study design is mixed methods using the explanatory model. The first study comprised of an online survey of graduates from the Centre for Medical Education, Dundee between 2008 and 2012. The data collected were sequentially explored in more depth through semi-structured interviews in the second study. To increase the range and scope of enquiry a third study was carried out, which involved a 10 month follow-up of a new cohort of face-to-face students (2013/14) through the course and to the workplace. The quantitative data were analysed using non-parametric statistics on SPSS 21, and constructivist grounded theory analysis was used for the qualitative data in ATLAS.ti 7. I found that a qualification in medical education enhances theoretical foundations in educational practices, with increased self-efficacy and engagement in scholarly activities. The qualification encourages transformational changes and epistemological development as a teacher, researcher, leader and learner. Many participants attributed their career progression to the qualification. The graduates were able to lead various educational changes in the workplace and they described substantial performance attainments. I also found their work environment and personal factors influenced the impact of these qualifications. A conceptual framework based on an increased understanding of the identity development of healthcare educators was also developed. This is the first study on the long-term effects of a degree-awarding course in medical education on healthcare professionals worldwide. The findings have implications for the educators, course directors, healthcare organisations and professionalisation of the speciality.

This thesis tells a story of a single year in the life of a primary care teaching practice from the multiple perspectives of clinical learners and those supporting learning. This story involves many people from junior medical students to nurses and doctors with twenty years of experience. It explores how they learn as clinicians. The research takes the form of a single descriptive case study based within a purposefully chosen GP teaching practice in West Yorkshire, England. The case study comprises interview, observational and documentary data collected over a single academic year in 2008/9. Interview data from 33 subjects were transcribed and analysed using thematic analysis within a modified grounded theory approach. The evidence from interview data was strengthened through direct and indirect observation and from documents relating to learning and teaching. I present a theory of how clinical learning occurs within the chosen practice, and on the nature of being a teaching practice. The findings are presented in the context of the existing literature of learning in this setting and within a theoretical framework of literature on social learning and communities of practice. Clinical learning appears to occur through engagement and opportunity. Engagement in learning is made up of four elements; recognition, respect, relevance and emotion. The elements are remarkably consistent across learner groups. Opportunity includes the availability, authenticity and immediacy of patient encounters; and the opportunity to learn with and from peers and professional colleagues. The research findings are consistent with existing work on social learning from other settings, but add to the literature. Engagement appears possible through recognition, relevance and respect and in the absence of meaningful participation, belonging or a clear trajectory of learning. Meaningful opportunities for clinical learning include those where patient encounters are made powerful through the authenticity that arises from the social and personal context of illness, and from the immediacy of hearing patient narratives de novo. The teaching practice studied in the case study is not dissimilar to others described in the literature of primary care learning, but this case study offers a far more detailed exploration of the elements which contribute to learning in the practice. These elements include strong whole practice support for learning, a skilled and committed clinical and educational workforce and a more indefinable additional element which is best summarised as a passion for education.

No description available.

This thesis outlines a study into institutional change analysing how certain senior individuals, called opinion leaders, were able to achieve change within the strongly institutionalized environment of medical education. It is situated in the complex and contested context of the English National Health Service, which for more than 60 years has seen numerous managerial, organizational, political and professional changes, which have impacted upon the roles and relationships of medical professionals, managers and government. Adopting a retrospective case study approach, the research centres on the specific case of the Enhancing Engagement in Medical Leadership (EEML) project, which had national-level sponsorship and status, directly involving a multitude of senior NHS bodies, representatives and individuals, to embed leadership and management training into medical curricula. Medical curricula are a mediated result of cultural, social, political and economic forces (Kuper and D’Eon, 2011) rooted in the construction of professional identity and transformation from lay person to professional. Prior to this project, there had been limited attempts to engage the medical profession in leadership and management conspicuously through the curriculum, because of the difficulty of including new content into already crowded specialty curricula, given the constraints of time and resources for medical training. Using conceptual insights into agency in institutional theory, such as institutional work (Lawrence and Suddaby, 2006) and institutional entrepreneurship (DiMaggio, 1988); practice theory (Feldman and Orlikowski, 2011; Nicolini, 2012); social position (Battilana, 2011) and capital (Lockett et al., 2014; Bourdieu, 1986), this study explores how project members enacted change within medical education. It analyses the processes involved in their actions and practices and establishes how this case furthers understanding of strongly institutionalized environments. Interviews were conducted with members of the EEML project team and steering group, many of whom had positions of influence and status in other relevant organizations in this field. In addition, a review of documentary data encompassing published and non-published project materials was undertaken. An open coding and thematic analysis approach was taken to gain deeper insight into the interview data, whilst the documentary evidence was used to confirm and support the interview analysis. This case study research reveals that contextual and environmental conditions, as well as exogenous shocks and endogenous motivation led to this change initiative occurring. Routine and recognised ‘practices’ resulted in significant change through embedding the Medical Leadership Competency Framework (MLCF) into contested medical curricula space. Opinion leaders were able, with other project members, to adopt an approach to change, understanding the prevailing conditions, identifying the project’s purpose and committing to an emerging form of practice known as ‘mirroring’. Moreover, this study explores how opinion leaders achieved change through making use of theirs’ and others’ capital resources to form a cross-field collective capital, known as system capital. Using this, they adopted a disposition in their practice beyond professions known as system centrism.

There is a well-established ‘achievement gap’ in medical education, with ‘ethnic minority’ students achieving less well in examinations than their white counterparts. The processes underlying this difference are currently unknown. Most research to date has taken a student-deficit approach, suggesting that lower performing students lack the cognitive or cultural capacity of their higher achieving peers. These models have so far failed to explain the variation in achievement by ethnicity. In order to address this gap in the literature and further our understanding of ethnic minority students’ underachievement, this thesis takes a sociocultural approach to the problem. It addresses two research questions: firstly, how does ethnicity impact on medical school achievement? Secondly, how do social networks affect achievement? This research uses qualitative interviews (n=33 medical students), quantitative survey methods and social network analysis (n=160 medical students) to explore ethnicity and the achievement gap within medical education. Sociocultural theories of learning, specifically concepts from communities of practice and Pierre Bourdieu are employed in the design and analysis phases. This thesis demonstrates that medical students’ achievement is best conceptualised as part of a wider learning trajectory toward becoming a doctor. Relationships are important channels through which the resources and support can flow, these in turn facilitate learning and achievement. Lower achieving students are less well connected to their PBL peers and have fewer tutors or clinicians in their network. The medical world has a tightly prescribed, yet often hidden, set of legitimate dispositions; students must learn to embody these norms, values and behaviours in order to succeed. This process relies on experiences of participation, facilitated by relationships with peers and seniors. Socialisation is clearly mediated by culture. Ethnic minority students, due to their differing cultural practices and identities, have fewer experiences of participation, often experience the medical domain as outsiders and find it harder to interact with tutors and clinicians. This is reflected in their social networks as some minority students have fewer seniors in their network. These factors interact to cut ethnic minority students off from potential and actual resources that facilitate learning and achievement. If the situation is to be improved, medical schools must do more to acknowledge the extra difficulties many ‘ethnic minority’ students face in becoming an insider. Processes of identification and participation must be supported as these students negotiate the extra distance and tensions between their home world and those of medical education and medicine.