Continuum of education
PIHR undertakes out a variety of research across the continuum of education, from undergraduate to postgraduate to continuing education. We have a rich tradition in pedagogic research ranging from explorations of methods of widening participation and decolonising the curriculum, to assessments of different pedagogic approaches. With respect to CPD, we undertake research on remediation and professional regulation.
Preparedness for practice
It is vital that medical graduates are prepared for their first day of work as a trainee doctor for many reasons. There is evidence to suggest that when trainee doctors start their first work placement as a Foundation Year 1 doctor (F1) in August each year, it has a negative impact on patient safety. Graduates being underprepared for practice also has an impact on the functioning of the broader healthcare team. Finally the transition from medical student to practising doctor is frequently experienced as very stressful.
Ensuring that graduates are prepared as well as they possibly can be for this challenging role eases this stressful transition. Studies show that there was a higher risk of burnout associated with those that rated themselves as feeling unprepared in their first year of practice and this effect was still evident for trainees who reported lower levels of preparedness seven years ago.
We have carried out a number of studies of preparedness to practice, including:
Medical Graduates Preparedness for Anticipated Healthcare Needs: The aim of this study is to investigate whether graduates are prepared for the future healthcare needs specifically: 1. the changing patient-doctor relationship 2. the doctor in a multi-disciplinary team and 3. complex clinical decision making. This research used a mixed methods design including a rapid review of the literature, inter-professional simulation and qualitative interviews with stakeholders. This study was funded by the GMC.
2020 Medical Graduates: The work and wellbeing of interim Foundation Year 1 (FiY1) doctors during COVID-19: All new doctors face challenges at the point of transition to practice, but FiY1s faced this in an extraordinary context. This GMC funded study explored the impact of Covid19 restrictions on medical students training and transition to work on their well-being
PIHR researchers have recently been making significant strides in the area of dental education research. Commissioned by the General Dental Council (GDC) in preparation of the UK leaving the European Union (EU), research led by PIHR's Professor Tom Gale explored dental education standards across the EU. This found variation between, and within, countries in the provision of dental education standards. In addition, the research found that there have been many proposals for harmonisation between Member States but little evidence of these having been implemented. Variation was also found in how dental education was quality assured. Further details can be found here.
We secured funding from Higher Education England (HEE) to investigate a new initiative in the South West called CLIP (Collaborative Learning in Practice) which is a coaching and peer-learning model for students’ placement learning that replaces the old mentorship model. The Nursing and Midwifery Council explicitly ended mentorship in 2018 with their new standards, and this coincided with our need to increase placement capacity.
Our research began in acute sector placements and has moved into the community. Adele Kane led this across the region as School of Nursing and Midwifery Associate Head of School for Placements and is currently HEE Fellow leading a project to roll out CLIP in GP nursing placements. Graham Williamson, Associate Professor in Adult Nursing in SNAM based in Exeter, was Principal Investigator for the research and lead author on the related publications. Our team, included nursing and midwifery, HEE and trust staff have generated several the publications about future nursing workforce. This engagement with local NHS, GP practices and private sector organisations is essential for impact as they are the future employers of our graduates.
Some of our publications on Nursing Education include:
Williamson, G R, Kane, A, Bunce, J, Jamison, C, Clarke, D, McDowall, C, Plowright, H. Collaborative Learning in Practice: videos to prepare students and staff. Nursing Times [online]; 117: 3, 49-51. 2021.
Williamson, G.R., Kane, A., Bunce, J., 2020. Student nurses, increasing placement capacity and patient safety. A retrospective cohort study. Nurse Education in Practice 48, 102889. https://doi.org/10.1016/j.nepr.2020.102889
Williamson G R, Rowe, L-M, Kane, A, Knowles, S. (2020). Preparation and support for students in community placements: a mixed methods study. Nurse Education in Practice https://doi.org/10.1016/j.nepr.2020.102747
Williamson, G R, Bunce, J, Kane, A, Jamison, C, Clarke, D. (2020). Investigating the implementation of a collaborative learning in practice model of nurse education in a community placement cluster. A qualitative study. The Open Nursing Journal, 14; 39-48. DOI 10.2174/1874434602014010039 .
Williamson, GR, Kane, A, Plowright, H, Bunce, J, Clarke, D, Jamison, C. (2020).‘Thinking like a nurse’. Changing the culture of nursing students' clinical learning: implementing collaborative learning in practice. Nurse Education in Practice; 43,102742 .
Williamson, G. R., Plowright, H., Kane, A., Bunce, J., Clarke, D. & Jamison, C. (2020) 'Collaborative Learning in Practice: A systematic review and narrative synthesis of the research evidence in nurse education'. Nurse Education in Practice, 43 pp. 102706.
The effective remediation of underperforming doctors has an important role to play in ensuring workforce sustainability. Proficient and safe doctors, operating efficiently within multi-disciplinary teams, are an essential part of the provision of high-quality and safe care for patients. If the performance of a doctor is lacking, patients may be at risk. Remediation is the process by which a doctor’s poor performance is “remedied” and the doctor returned to safe practice. Remediation can be formally defined as “an intervention, or suite of interventions, required in response to assessment against threshold standards”. Threshold standards are set by regulatory bodies to keep patients safe. It is thought that, at any time, around 6% of doctors in the hospital workforce may be performing below the standard that is expected of them.
As there is a shortage of doctors in the NHS and a fully trained doctor will have cost the taxpayer approximately £500,000 to train, offering remediation to retain expensively trained but underperforming doctors is a logical financial solution. Remediation is, therefore, an important facet of workforce retention and has a direct impact on patient safety.
A programme of research on the remediation of doctors’ is being carried out by members of the CAMERA team. The specific areas of the remediation research agenda being addressed include how remediation interventions produces their effects, the impact of remediation on professional identities, the remediation of professionalism lapses and optimising the delivery of remediation programmes.
RESTORE 1 was conducted in collaboration with the Universities of Oxford and Aberdeen. This used realist review methods to develop a programme theory to explain how remediation interventions produce their effects. It is fundamental to understand the theory of how remediation of doctors is supposed to work, for whom and the contexts that lead to different outcomes, in order to design high-quality remediation interventions. The findings of this review were used to develop guidelines for tailoring and implementing effective remediation interventions for practising doctors. The study was funded by the NIHR HS&DR.
Led by Dr Nicola Brennan, Senior Research Fellow in Medical
Education, a team from the Collaboration for the Advancement of Medical
Education Research and Assessment (CAMERA) research group are undertaking a
£662K project looking at how the NHS can address underperformance among
doctors. Following on from team’s previous work on the RESTORE1 project,
RESTORE 2 will examine how the NHS can optimise remediation – the range of
interventions aimed at improving doctors’ performance if they slip below
Remediation and professional identity
An important and under researched area on the remediation agenda is the impact undergoing a remediation programme has on the identity of a doctor. A PhD studentship being undertaken by Dr Jamie Read is using questionnaires and interviews to understand how remediation impacts on the professional identities of medical students and identify how remediation might be used to support appropriate identity formation. The output of the PhD will include a conceptual framework, from which interventions that better support students can be developed.
Remediation of professionalism lapses
The CAMERA team have a particular interest in the remediation of professionalism lapses in doctors and have carried out a systematic review of the literature to synthesise the evidence on existing interventions in this area. This review highlights the additional complexities of remediating professionalism issues compared to knowledge and skills.
Some of our publications Remediation:
Price T & Archer J 2017 'UK Policy on Doctor Remediation' Journal of Continuing Education in the Health Professions 37, (3) 207-211 , DOI PEARL
Price, T, Brennan N., Cleland J., Prescott-Clements, L., Wanner A., Wong G & Archer J., 'Remediating doctor’s performance to restore patient safety: a realist review protocol', BMJ Open
Price T, Brennan N, Wong G, Withers L, Cleland J, Wanner A, Gale T, Prescott-Clements L, Archer J, Bryce M (In Press) Remediating doctors’ performance to restore patient safety: A realist review (RESTORE) Health Services and Delivery Research Journal.
Price T, Wong G, Withers L, Cleland J, Wanner A, Gale T, Prescott-Clements L, Archer J, Bryce M, Brennan N (in Press) Optimising the delivery of remediation programmes for doctors: a realist review. Medical Education.
Brennan N, Price T, Archer J & Brett J (2019) Remediating professionalism lapses in medical students and doctors: A systematic review. Medical Education
Our research focuses on successful strategies to recruit and select people with the personal skills and attributes valued by healthcare providers. This work has underpinned the successful implementation of national selection methods for postgraduate medical training posts in anaesthesia and methods to recruit to undergraduate nursing posts in Northern Ireland.
We have utilised the UKMED database to seek answers to questions regarding what individual characteristics are associated with doctors’ choices to apply to certain specialties in postgraduate medical training and how best to identify widening participation students at undergraduate entry.
Figures from the Centre for Workforce Intelligence predict increasing shortfalls in the numbers of qualified specialists across many disciplines and we are working with regulators such as the GMC and GDC to understand patterns of migration of registered practitioners in and out of the UK as well as factors affecting these trends.
Workforce has become a top concern for NHS trusts across the country. Demand for services, and in turn demand for staff to deliver services, has grown more quickly than the pipeline of new staff. Workforce pressures have been exacerbated in recent years by the increasing difficulty in recruiting and retaining overseas staff and the workforce stress presented by Covid19.
PIHR researchers are engaging in workforce stress related research across a number of clinical areas, including social work, nursing and midwifery and have also been looking at the need for recovery amongst emergency physicians in the UK and Ireland.
Recent examples include a rapid evidence review on the mental health of dental professionals. The study led by Anastasios Plessas, in collaboration with the University of Southampton and with funding from the General Dental Council, concluded that dentists suffer an increased level of stress and burnout, particularly general dental practitioners, with litigation and regulation the main stressors. Similarly research led by Professor Bridie Kent, involving surveys of the UK nursing and midwifery workforce found concerning levels of post-traumatic stress disorder (PTSD), stress and anxiety in respondents.
Research in the pipeline includes our plans to extend our surveys on factors associated with stress in the social care workforce to other public and third sector workers providing care for vulnerable people, the stress involved in breaking bad news, and developments in mindfulness apps.
Some of our publications on workforce development
Aslet M, Paton L, Gale T, Tiffin P. 2019. Evaluating the recruitment process into UK anaesthesia core training: a national data linkage study of doctors’ performance at selection and subsequent postgraduate training. Postgraduate Medical Journal http://dx.doi.org/10.1136/postgradmedj-2019-136390
Lambe P, Gale T, Price T, Roberts M. 2019. Sociodemographic and educational characteristics of doctors applying for psychiatry training in the UK: Secondary analysis of data from the UK Medical Education Database project. BJPsych Bulletin DOI: https://doi.org/10.1192/bjb.2019.33
Gale TCE, Lambe PJ & Roberts MJ. 2017. Factors associated with junior doctors’ decisions to apply for general practice training programmes in the UK: secondary analysis of data from the UKMED project. BMC Medicine DOI: 10.1186/s12916-017-0982-6
Traynor M, Galanouli D, Roberts MJ, Leonard L, Gale TC. 2016. Identifying applicants suitable to a career in nursing: a value-based approach to undergraduate selection. Journal of Advanced Nursing DOI: 10.1111/jan.13227
Roberts MJ, Gale TCE, McGrath JS & Wilson MR. 2016. Rising to the challenge: Acute stress appraisals and selection centre performance in applicants to postgraduate specialty training in anaesthesia. Advances in Health Sciences Education.
Contributing to Net Zero
Medical, nursing and Allied Health Professionals (AHP) are crucial players in the NHS’s commitment to becoming a ‘Net Zero’ NHS. The effective implementation of this goal requires strategic vision and resourcefulness from educators, practitioners and students (future leaders).
The climate emergency is also a health emergency, threatening the core purpose of the NHS, putting at risk the health and wellbeing of patients and communities. Unabated, climate change will disrupt care, affecting patients and the public at every stage of their lives. Visionary change-makers, therefore, are crucial to support current and future NHS green leaders. Pettinger has reviewed sustainable eating for nutrition professionals, working closely with her professional body (the BDA) to champion both pedagogic research and practical policy application via the pioneering One Blue Dot Toolkit (link to short vid). This has led to her co-developing the new Greener AHP hub. She is also working with the Business School on ‘collaborative leadership for sustainability in AHPs’ to develop this work further.
CAMERA is a leading centre in health professions regulation research, with our work including research on a range of regulatory policies and processes, including Fitness to Practise, licensing and revalidation. We engage with key stakeholders to inform policy development and implementation and to understand the impacts of regulation on professional practice.
Our research in this theme also links to work across other CAMERA themes, as professional regulators play a key role in setting educational standards and quality assuring professional education, and are also taking an increasing interest in workforce issues.
Fitness to practise
Fitness to practise processes are a central feature of professional regulation, and our work in this area explores: the complaints and referrals which prompt fitness to practise proceedings; the functioning of fitness to practise procedures themselves; and quantitative analyses of trends within fitness to practise data.
CAMERA’s fitness to practise research includes studies commissioned by the General Dental Council, the Nursing and Midwifery Council, and the General Medical Council.
Recent work has focused on seriousness in fitness to practise, exploring how the concept is understood and applied by within professional regulation. In 2018, we undertook a literature review on this topic, commissioned by the General Dental Council, and we are currently carrying out further research in this area.
As well as work on regulatory fitness to practise procedures, we also undertake research into local and organisational performance management and disciplinary processes for healthcare professionals.
Tazzyman, Bryce M, Boyd A, Walshe K. 2019. ‘Identifying and managing concerns about general practitioners: an interview study and case series analysis.’ British Journal of General Practice, 69/684, e499-e506, https://doi.org/10.3399/bjgp19X703733
Bryce M, Archer J, Brennan N, Burns L, O’Brien T, Price T. 2018. Fitness to Practise: Impairment and serious misconduct – a narrative synthesis review. General Dental Council.
Since 2010, CAMERA has undertaken research into the development and introduction of medical revalidation, a relicensing process which aims to ensure that doctors remain up-to-date and fit to practise through engagement in appraisal processes. Our team took part in two major national evaluations of the implementation of this flagship regulatory policy, between 2015 and 2018, funded by the General Medical Council and the Department of Health Policy Research Programme. This programme of work explored the impacts of revalidation for the medical profession and for healthcare organisations.
Price T, Tredinnick-Rowe J, Walshe K, Tazzyman A, Ferguson J, Boyd A, Bryce M. 2020. ‘Reshaping clinical governance: a qualitative study of reforms to professional regulation and their effects on clinical accountability in the NHS in England.’ Health Policy, 124/4, 446-453
Tazzyman A, Bryce M, Ferguson J, Walshe K, Boyd A, Price T, Tredinnick-Rowe J. 2019. ‘Reforming regulatory relationships: the impact of medical revalidation on interactions between doctors, employers, and the General Medical Council.’ Regulation & Governance, 13: 593-608
Baines R, Zahra D, Regan de Bere S, Bryce M, Archer J. 2019. ‘A “futile exercise”? Psychiatrists’ perceptions and experiences of patient feedback for relicensing purposes in the UK.’ Academic Psychiatry, 43(6):570-576
Tazzyman A, Ferguson J, Boyd A, Bryce M, Tredinnick-Rowe J, Price T, Walshe K. 2019. ‘Reforming medical regulation: a qualitative study of the implementation of medical revalidation in England, using Normalisation Process Theory.’ Journal of Health Services Research and Policy
Wakeling J, Holmes S, Boyd A, Bryce M, Cameron N, Marshall M, Tredinnick-Rowe J, Archer J. 2019. ‘Reflective practice for patient benefit: an analysis of doctors’ appraisal portfolios In Scotland.’ Journal of Continuing Education in the Health Professions, 39/1, 13-20
Bryce M*, Luscombe K, Boyd A, Tazzyman A, Tredinnick-Rowe J, Walshe K, Archer J. 2018. ‘Policing the profession? Regulatory reform, restratification and the emergence of Responsible Officers as a new locus of power in UK medicine.’ Social Science & Medicine, 213, 99-105.
Walshe K, Boyd A, Bryce M, Luscombe K, Tazzyman A, Tredinnick-Rowe J, Archer J. 2017. ‘Implementing medical revalidation in the United Kingdom: findings about organisational changes and impacts from a survey of Responsible Officers.’ Journal of the Royal Society of Medicine, 110/1, 23-30.
The introduction of a national medical licensing assessment in the United Kingdom is a major change in medical education in the UK, and CAMERA was commissioned by the General Medical Council to synthesis the evidence base on the impact of these types of assessments internationally.
Price TJ, Lynn N, Coombes L, Roberts M, Gale T, Regan de Bere S & Archer J. 2018. 'The International Landscape of Medical Licensing Examinations: A Typology Derived From a Systematic Review.' International Journal of Health Policy and Management
Archer J, Lynn N, Coombes L, Roberts M, Gale T, Price T & Regan de Bere S 2016 'The impact of large scale licensing examinations in highly developed countries: a systematic review.' BMC Medical Education 16/1
The Collaboration for the Advancement of Medical Education Research and Assessment (CAMERa) researchers aim to improve the development and sustainability of the healthcare workforce by focusing on three research themes, namely workforce development, continuum of education, and professional regulation.
CAMERa's research programme, carried out by a multi-professional group and employing a mix of qualitative and quantitative methods, impacts directly on national and international literature, educational theory, practice and policy.