Introduction Clinical decision-making, situation awareness, task management, and teamwork are key non-technical skills (NTS) required by junior doctors. However, research has demonstrated that new doctors have difficulty demonstrating effective NTS behaviours. Tactical decision games (TDGs) are low-fidelity classroom-based activities designed to develop proficiency in NTS. They have been used in other safety-critical industries to develop NTS but their use in undergraduate medical education has been very limited. This aim of this thesis was to explore the potential role of TDGs as a novel method of developing final year medical students’ NTS. Methods Throughout this thesis a qualitative approach was taken, underpinned by constructivist epistemology. In the first instance the feasibility and acceptability of using generic (non-medical) TDGs with groups of final year medical students was explored. Thereafter, the use of non-medical TDGs and acute care simulation scenarios to develop NTS was investigated. Acute medical TDGs were developed with support and guidance from an expert panel. The potential role of medical TDGs to develop final year medical students’ NTS was then explored. Medical TDGs were then implemented into the core undergraduate curriculum in the clinical assistantship programme. Results In the feasibility study six key themes emerged from the data: ‘‘the value of non-medical games’’; ‘‘giving and receiving feedback’’; ‘‘observing and reflecting’’; ‘‘recognizing and understanding NTS’’; ‘‘dealing with uncertainty and ambiguity’’, and ‘‘introducing TDGs into the curriculum’’. Exploring the use of non-medical TDGs and acute care simulation to develop NTS, five key themes emerged from the data: “situation awareness and fixation”; “expectations influencing behaviour”; “being uncomfortable with uncertainty”; “transmitting and receiving information” and “working with peers and seniors”. Using acute medical TDGs to develop NTS, five key themes emerged from the data: “understanding capabilities and responsibilities of team members”; “prioritising in a busy clinical environment”; “developing a workable solution”; “relating medical TDGs to clinical experience” and “introducing medical TDGs into the undergraduate curriculum”. A team of facilitators were trained and medical TDGs delivered to the full final year cohort in the clinical assistantship programme. Discussion and conclusions This thesis has found that generic and acute medical TDGs represent an exciting potential method of teaching medical students NTS. TDGs appear to be versatile activities that can be adapted to meet the needs of participants in different contexts. As such, the full potential of TDGs in the undergraduate curriculum and beyond remains to be explored.

A quantitative survey was conducted in two Canberra hospitals that aimed at ascertaining the impact of information provided by medical libraries on clinical decision making. Specifically, this research study investigated clinical, cognitive and quality value of information provided by the medical librarians to the management of patients and doctors' ability to handle clinical cases differently as a result of such information. Furthermore, the relative value of information received from the library was assessed by comparing it to the value of information received from other sources in dealing with clinical problems. The research involved medical specialists and registrars affiliated with these hospitals. Doctors were asked to select any clinical situation which they frequently or currently encounter and for which further information would be useful to them. Once their information requests were identified, they were then asked to present such requests to the hospital library. In order to avoid any special treatment, participants were urged not to identify themselves to the library staff as partaking in the study. It was important that participants did not search for the information themselves. The doctors were asked to evaluate the material provided by the library in relation to clinical care and, thereafter, complete a short questionnaire. This research took place between October 1994 and March 1995. The questionnaires were sent to 288 doctors. This represented the total population of specialists and registrars affiliated with both hospitals at the time of the study. Analysis of the results is based on a 34% useable response rate. Medical specialists were by far the higher number of respondents (70%) as compared with registrars (30%). Eighty-one per cent of the doctors said that the information provided by the library refreshed their memory and 82% said that it would contribute to better quality of medical care. Eighty-six per cent indicated that some of this information was new to them and 99% said that the information provided was up to date. Ninety-four per cent said that the information provided by the library was of clinical value to them. As the result of the information provided by the library 75% of respondents would either definitely or probably handle some aspects of the clinical situation differently than they would have done it otherwise. The level of importance of the change for the optimal care of patients was assessed with 54% regarding it as important, 42% as moderately important. Specifically, as the result of the information provided, the doctors were able to change the following: diagnosis 10%, choice of lab tests 20%, choice of other diagnostic investigations 24%, choice of drugs 27%, choice of other management 58%, reduce length of hospitalisation 10%, post-operative care of patients 25%, advice given to patients 47%. On the basis of the received information the doctors were able to avoid the following: hospitalisation of patients 11%, risk of hospital acquired infection 8%, surgical intervention 19%, tests or other investigation 23%, additional out-patient visits 12%. Discussions with colleagues were reported to be most valued sources of information for the purpose of clinical decisions (59%), followed by diagnostic imaging (49%), librarian (45%), lab tests (42%) and patients' medical records (30%). The librarian's role as contributing to the process of clinical decisions was rated highly with 88% ranking it as either important or moderately important. The results of significance p test statistic performed at 0.05 significance level suggested that, for this study, there was a significant relationship between the frequency of library use and doctors' ability to change the choice of laboratory tests, diagnostic investigations, and the choice of prescribed drugs. The results of this research study demonstrate that medical librarians can positively contribute to clinical management of patients by providing timely and accurate information. Further research is recommended in order to determine the impact of the whole range of library services on health care outcomes.