Transition of Students into Novice Practitioners - Essay Example

? Transition into Novice Practitioners Introduction The successful transition of a to a novice practitioner is one of the mostfundamental challenges for a medical student. The medical schools encourage diversity of curriculum to inculcate responsibility and adaptability in the students. Evidence shows that the students vary greatly in the levels of their preparedness for their initial posts. According to a report, over 40% of the medical graduates of the UK did not feel prepared enough for becoming practitioners in the nation’s health care system (Council, 2003). Although more recent surveys show an improvement in this graph, but there is still great variation. This paper aims at studying the problems and phases of transition from a student to a novice practitioner in health care and possible policy changes in this context. 2. The transition Where the transition from a student to a doctor is challenging and stressful indeed, it is also a rewarding experience (J., 1987). Medical schools train the students in practical skills but there is a substantial difference in application when the trainee becomes a practitioner, not only in the skills department but also in the responsibilities (Williams C, 2001,). When the relationships change and new coping strategies become inevitable, the importance of knowledge and skills which seemed irrelevant during undergraduate years becomes apparent. 3. Preparedness The existing literature on the subject shows that the majority of the students felt that their training did not provide sufficient development of practical skills for the hectic work environment of public health care units (R., 2007). An analysis of this study shows that some problems in the transition arise because of a mismatch between actual requirements in health care practice and the prescribed outcomes of undergraduate education, while other problems might be the result of changes in the working routines such as adjusting to shift-work. Taking direct responsibility for the patients care in a social health care system is quite different from learning medicine in a carefully supervised context (Lempp H, May 2004). It is noteworthy here that the previous generations of UK medical students had more opportunities to take responsibilities early on in their studentship, such as working as locum house officers whilst they were senior students and thereby undergoing some of the pressures of real practice. A thorough analysis of the situation shows it is not the work itself which leads to problems with the transition, but the changed circumstances and practice, for example the medical schools have an approach of teaching patient centered care but this culture can be perceived as a hampering to the pace of work, and the lack of supervision and a sudden overload of work also plays with the mindsets of the students (Watmough S, 2006). An important area of concern is prescribing; an evaluation has found that the new practitioners feel that they are lacking in know-how for safe prescribing. Another important factor is that of stress which is experienced by these novice practitioners. Majority of the stress causing agents come from the organization rather than the individual himself. In the healthcare system, overwork is a major headache, aided by the uncertainty of the novice practitioners of where to look for help and the onslaught of too much responsibility so early in their careers without sufficient supervision. Legislation, like the European Working Time Directive, has helped improve the working environment, but has also somewhat increased the rift between the juniors and the seniors who do not think much of their juniors’ commitment levels (Watmough S, 2006). 4. Factors Affecting Preparedness The primary factors that affect the move from student to a new practitioner encompass two categories: they might be internal including the individual’s learning style and personality, or they might be external including the structure of the organization in which they work. Research indicates that some individuals seek learning opportunities more enthusiastically, staying late and observing more, volunteering for night shifts etc. (J., 2006). The inclination of personal interests also aids preparedness of the individuals as those who opt for acute care in electives fare better in the wards than those who don’t. External factors hold more weightage in determining the number of challenges faced by the new graduates (Tamblyn R, 2005 ). The transition of these students is directly affected by the local structure of the organization, the administration and the staff, especially in national healthcare institutes. The placements inside the hospitals are vital as those placements where the student is made to perform more tasks rather than made to merely stand in the corner (Pearson SA, 2002). A longer shadowing period is thought to be more effective in inculcating the feeling of being part of a team in the young trainees. 5. Practice The studies indicate that there are a number of areas where the junior doctors can face problems in adapting to the nature of their work (Goldacre MJ, 2008). These include the more clinical aspects like that of practical procedures and prescribing as well as less openly clinical but important factors such as the handling of the paperwork and learning to prioritise in the busy health care environment, learning the administrative procedures as well as basic communications skills and adjustment to ward work team work and shift timings. The problems arise because of some explicit gaps in the knowledge and basic training. 6. Practical Skills There is a general concern about several areas of practice. Some of the students get through medical school with little experience with real patients, having practiced more on mannequins and simulators, particularly when it comes to cannulation and catheterization (GB., 1994). Such circumstances require the staff to be especially supportive and co-operative to these young trainee practitioners, and help them overcome the deficiencies in practical application of their knowledge. When some of the individuals find themselves without much help from the staff, face a situation of sink or swim (Langdale LA, 2003). A solution to this is found when the practitioners have to deal with so many patients that the sheer number of procedures they do become their rectifiers. There is a general consensus that most new practitioners are not getting as much experience on ward as they require. a. Patient Management The students are prepared by the medical schools to receive patients and take their medical histories. But the transition of these students into practitioners exposes them to an environment where they have to make critical clinical decisions and manage their patients (S., 1996). Although it is hard to prepare for the inevitable change in responsibility that is attached to being a doctor, there still is particular concern over the capability of the new doctors to handle acutely ill patients. Studies indicate that being the first doctor to deal with a critical patient is worrisome for most F1 doctors, though some did feel confident in dealing with commonly occurring medical emergencies like cardiac arrests by the end of F1 (Paice E, 2002). The acute patient management is something that can only be taught in the real environment of a public hospital rather than in a classroom. Therefore, the best way to teach this to the novice practitioners is by exposing them earlier on with critical patients, where they have to be the first ones to make a decision and be responsible for the initial management of the patient, like in night shifts or during out of hours. b. Prescribing There is a general consensus among the researchers of the subject that there is a lack of preparedness for prescribing. The biggest step in the transition of a student into a novice practitioner is handling and learning the art and science o prescribing. Research has proven that prescribing is one of the weaker areas of these transient individuals (van Zwanenberg T, 2006). Prescribing consists of two distinct yet related areas; one is the basic scientific pharmacological knowledge of the drugs, including their interactions and effects, and the other is the working mechanics of prescribing including calculation of dosages and writing prescriptions and drug charts. The balanced amalgamation of these bases, both knowledge and procedural, result into a developed prescriber. The weaknesses of the junior doctors encompass both the skill base and the knowledge base. Some pharmacists express grave concerns regarding the prescribing done by the junior doctors, in both the areas of pharmacological knowledge as well as the understanding of the practical aspects of prescribing (Lempp H, March 2005). The complaints against the junior doctors range from their laziness or lack of appreciation for the importance of taking proper thorough drug histories and ensuring the proper completion of the drug charts. Most of the mistakes are minor in nature and are easily seen and rectified by the nurses and pharmacists, but it still is the main source of error. The development of the knowledge base is thought to be the primary task of the school education, but prescribing is such a high order task that the practical application of the knowledge base becomes the starting point for the junior practitioners in really understanding the dynamics of prescribing (Albert, 2007). The complicated process of selecting appropriate drug and determining its side effects and contraindications and then determining the correct dosage, can only be mastered when repeated several times in a hospital environment. c. Communication Skills Communication skills are as essential in medical practice as they are in any other field. Doctors have to use these skills in a variety of ways when dealing with patients and colleagues. The previous researches show that it is an area in which most of the new doctors face little problem, yet it holds extreme importance. Sometimes the junior doctors feel hesitant in asking their seniors anything because they feel competent with them. This sometime leads to harmful experimentation. The modernizing Medical Careers program introduced the Foundation Program and the grade F1 (WC., n.d.). The F1s are exposed to more awareness of their specific roles and are also told of the limitations they will experience and the relevant guidance they have to seek. This instills the confidence in them to ask for help in the areas they perceive they are weak. Studies show that the skills of higher order, like that of breaking bad news, are the primary areas where the new doctors need to develop their skills further, through observation and careful practice (Hrisos S, 2008 ). Research also indicates that F1s still felt less confident in handing out bad news by the end of the first year of their practice. At this point, some also complain of the poor communication by staff and internal staff conflicts. The communication skills need to be honed up by the institutions as it is one of those skills which need to be pushed into practice immediately and can’t wait to be developed while on the job (Evans DE, 2004). The seniors say that undue emphasis on communication skills can cost time in which the students can learn other knowledge skills. But the modern research has proved that in the modern world, communication is a very crucial process, as sentiments of the relatives are hard to deal with without these skills. These skills are polished on the job, and new doctors take a lot of time in gaining the confidence to be able to break bad news to the relatives. d. Prioritizing There is a limitation to the level to which the theoretical knowledge, and limited practical knowledge gained in a carefully supervised environment, can be transferred to a complex healthcare unit working environment. This includes working the night shifts and on call duties, handling and managing the paperwork and policies of the hospital, adapting to the time management and learning to prioritize and dealing with acutely ill patients (Cave J, 2007). Previous literature has also pointed out that the art of prioritizing is also something the new practitioners become exposed to for the first time after their transition and managing the workload through prioritization is something they have to learn while working on the wards. More experience with night duties and being on call during student years is beneficial in making the novice practitioners more accustomed to the tough routines of hospitals (Keller DR, 2004 ). e. Time Management Research has shown that most individuals find time management to be significantly challenging in the first year of their practice. At the end of the first year, they feel that their time management skills have improved sufficiently. The doctors in the healthcare system, although, consistently complain of excessive workload, and find it hard to squeeze personal time out of their work schedules. The above points of doing quick prioritization, handing out quick prescriptions aided by quick calculations of dosages, concise effective communication, carrying out the procedures quickly, all come into play when we talk about the effective time management. f. Managing Paperwork Some of the individuals report experiencing difficulties in the administrative responsibilities like ordering tests and investigations, as these vary between different hospitals and trusts. Some have expressed concerns on the paperwork, for example in writing patients’ notes and writing discharge summaries, or filling death certificates and cremation forms (Langford NJ, June 2004). There are suggestions that paperwork can be given a little more emphasis in the medical schools, for example in teaching appropriate drafting of clinical paperwork like blood forms and referral letters. 7. Knowledge of the NHS and Legal and Ethical Issues Another area of a lot of concern is the familiarization of the new doctors with the legal and the ethical issues of the nature of their jobs, and a worthwhile understanding of the NHS. At the end of the first year of practice of the F1s, they do accept to have gained knowledge of the NHS, but yet that knowledge is mostly limited to the local NHS operation and partial, applicable within the hospital and among the local providers rather than encompassing NHS nationally. But mostly, the gaps in the NHS knowledge are not perceived as a big problem. The determinant of difference is the size of a hospital, in a relatively small hospital there is more local support and a plane organizational structure, but in such a hospital there is also more inter-organizational contact as less services are available on site (Stewart, 2008). The major part of the learning is done through informal means, mainly from doing the job and also from conversations with senior colleagues. 8. Being a Trainee The novice practitioners might have made the transition from being a student to being a practicing doctor, the process of learning continues regardless of this transition (KV., 2002). In the light of this fact, the trainees are still in the process of learning and have to, therefore, look for learning opportunities to complete their learning portfolios while being on a job. The learning of these individuals mainly depend on the opportunity availability and their personal attitude towards learning. 9. Improvements to Training The analysis of this study can be summarized as follows: 1. The new graduates look forward to being a doctor, which is a reward of years of training and they are excited about finally having an effective role to play in a clinical team. The transition from student to doctor was a step up in their responsibility and they experienced a steep and difficult learning curve. 2. They are under prepared for some demanding communication tasks despite being strongly trained in communication skills at graduation. These tasks include breaking bad news to patients, handling challenging colleagues and dealing with angry or distressed relatives. 3. Basic clinical skills are practiced a lot as undergraduates, but they are not in the context that adequately mimics the real hospital environment, which involves the need to prioritize, multiple demands on time and the responsibility of taking care of acutely ill patients. 4. At the start of the practice, the knowledge of non-clinical areas involving legal and ethical issues and the operation of NHS is lacking. Even the growth in the successive months is limited to local NHS. 5. Prescribing is a significantly problematic area for the undergraduate. The teaching does not prepare new graduates properly enough for clinical pharmacology. Unfortunately, several changes might be detrimental and result in less clinical exposure for the final year medical students. They are: • The change in the sense of team work and the lack of a sense of belonging has resulted from the application of shorter placements and shift-work, driven mainly by the European Working Time Directive. This was not the case in older traditional teaching in medical schools. • The feeling of the Foundation doctors to increase their experience of practical skills themselves and, therefore, not entrusting to practical procedures of the seniors, and other tasks which were previously more in the student domain. • In this context, the multi-disciplinary teams possess a complex mix of authority and skill which results in fewer opportunities to access patients and more competition. The fact that the senior students give priority to library based learning over experiential learning which accrues from the maintenance of presence in the wards can be another factor. The changes in NHS structures and treatments also have an impact on the level to which students feel they can be involved. The patients have increasingly shorter stays in hospitals and they tend to be more critically ill than in the past, which results in less access of students to acutely ill patients concluding in a less legitimate and more peripheral student to patient contact. From this research, it can be deduced that the initial transition period from a student to a novice is a journey which develops intellectual, professional, emotional, social and organizational skills and guides novices all the way to become an expert practitioner (Hoff TJ, 2004 June). During this journey, they face several hurdles about their responsibilities towards the society and about how to conduct them in good manner. There have been many conflicts between the educational guidelines of morals, ethics and policies and in professional ethics and culture. The novices get confused about what is the right path to adapt since all the rules are fresh in their minds as compare to those who are in the practical life for years. This discrepancy of the apparent contrast between the responsibilities, knowledge and performance expectations which are required within an academic environment and in professional life must be removed at any cost so that the new graduates must not consider them a fool while starting their practice. Students are used to be taught by the instructors and they rely on their supervision throughout the academic career (Council., 2006). When they enter into real world of practice, there is no one to guide them; instead there are people who do not want that they took the same place. So they try to make every possible means by which novice gets frustrated, disappointed and want to leave the profession. These novices are not prepared for such transition shocks as they had high expectations from their professional lives and they never thought to leave it prior to when they are exposed into the market. They are of the view that as soon as they will graduate, there will be a welcoming environment outside which will help and guide them all the way and thus they will easily adapt the new role and responsibilities of a practitioner. They will easy amalgamate their knowledge along with the cases and it would not be much difficult at all. But the entire scenario is quite different from their thoughts and expectations when they find the reality of practice and professional stage. The data shows that an increased quality of clinical practice would be helpful in producing an increase in the preparedness. This experience is also imperative in preparing the students for hospital protocols and procedures in areas such as requesting scans or tests, prescribing and informal cultural aspects of the inter-team communication in hospitals. The learning opportunities to provide such an experience are limited however, mainly due to the fact that the undergraduates have no formal role in the team and are effectively outsiders looking in. The availability of more time on wards and a lengthier shadowing period are potentially useful changes, but it is clear that this time should be more participative and more structured to be more effective. The inclusion of the situated learning has to be implemented so that the students can learn the most in the first few months of their practice. Theories of situated learning generally refer to learning in the workplace as a process of enculturation of individuals into the real practices via appropriate supported participation and authentic activity, which means through a legitimate peripheral participation. The learners are allowed to participate ‘legitimately’, that is their participation matters to the community’s successful performance. Their role moves more to the ‘Centre’ as they become more skilled and competent, from initially ‘peripheral’ roles in the community, and eventually resulting in full participation. 10. Conclusion and implications for policy This study can points out to one basic and fundamental conclusion that the preparedness of the undergraduates would benefit by increased experiential learning in the clinical practice. It is in the GMC’s interest to accept and implement this conclusion, by ensuring that the undergraduate programs policy and the transition of the student into a novice practitioner involve maximum gain of salient clinical practice experience (D., 2002 ). In the current policy, the emphasis on gaining experience is conspicuous only by its absence. Everything besides gaining experience on the job is heavily highlighted, including skills, attitudes and knowledge, but experience takes a back seat. The results of this study indicate that the hospital experience is variable at the moment and is mainly dependent on the interpersonal relationships between students and the clinicians with whom they are placed and the organizational factors. In light of this study, a key recommendation in context of policy is that documents like the Tomorrow’s Doctors explicitly emphasize and prioritize the practical experience medical students ought to receive, specifying its amount and type, mainly towards the end of the undergraduate program. Increase in this experience will be helpful in developing the knowledge and skills, which are already specified previously. The suggestion from the data demands that the existing policy guidelines should be more prescriptive and explicit, and most importantly, the duration of shadowing should be extended. The current initiatives to increase the undergraduate clinical hospital experience, which are under trial in several medical schools, have to be periodically reviewed so that the effective guidelines for clinical placements could be pointed out and a methodology could be devised for their further development. To facilitate changes and developments like these, the institutes and places where medical students and F1s are learning, should have an encouraging learning culture with a lot of opportunities. The GMC’s QABME (Quality Assurance of Basic Medical Education) process can be helpful in providing the means to shape such a change. Therefore, the priorities for the GMC should be: 1. Ensuring that the undergraduate clinical placements have more consistency and structure, inclusive of experiential learning over a wide range of specialties in order to balance the opportunistic learning which is currently taking place. 2. Ensuring greater roles for the medical students in the teams and also a greater involvement in them, with due regard to the safety of the patient. Clinical placements have to consider the dimensions of centrality and legitimacy so that the student is made to move into a more central and authentic role before taking on the full responsibilities of a F1. 3. Establishing comprehensive guidelines on shadowing and ensuring they are more prescriptive of content and structure, and aim at ensuring, rather than merely recommending, that new F1s have shadowed their own job adequately. Foundation schools have to be encouraged to ensure that the induction events do not take shadowing trainees away from wards. 4. Specifying the limits of the roles of F1 and the boundaries of their responsibilities with regards to the senior doctors and other members of a multi-professional team. 5. 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Williams C, C. P. &. C. M., 2001,. The doctor–patient relationship: from undergraduate assumptions to pre-registration reality. Medical Education, 201 Volume 35( Number 8), pp. 743-747. Read More