Clasificación de los procesos de lodos activados

We now consider the very first few days of being an F1 – the ‘August transition’ period (with n=53 PIN/GINs (3.1%) being coded to this sub-theme; 7 (13.2%) were coded as trainees being prepared, 29 (54.7%) as unprepared and the remainder were general narratives around the final-F1

transition, sometimes comparing todays’ experiences with the experiences of how things used to be). Different stakeholders talked about this in different ways and to different extents, with the F1 trainees and FRTDs discussing this more frequently than other groups (with no data from P_GVT or EMP groups) and providing the majority of our data on preparedness. Only one PPR group member drew on personal experiences (she was an ex-healthcare worker) the remainder drawing on second-hand understandings of the transition period as reported in the popular press. Indeed, the perceptions of this transition period from one PPR group appeared quite unambiguously negative, suggesting that August was a very bad time to get sick and that hospital was to be

avoided at all costs (see Box 16, Excerpt 1). Such public perceptions of the first few working days of F1s appear to be founded on hearsay, and media coverage of this transition time. However, similar concerns were talked about by a few F1 participants (Box 16, Excerpt 2), who cited the ‘all change’ on the same day in August as their biggest concern regarding patient safety.

In terms of preparedness (rather than unpreparedness), our data came from discussions within F1, FRTD and HCP stakeholder group discussions. Factors that seemed to facilitate preparedness were familiarity with the specific working environment in which F1s were entering, graduates’ feelings of confidence that they have attained the right level of training in practical procedures, and have the appropriate communication skills to talk with patients and engage in joint decision-making activities (Box 16, Excerpt 2).

For F1 and FRTD participants, one way of understanding personal experiences of the August transition period is by considering not just what they said about preparedness, but paying attention to how they talked about this transition time. Their narratives were replete with vivid

metaphors about the enormity of their new F1 role: they talked about ‘feeling completely alien’, taking ‘that step’, ‘the biggest jump’, feeling as if they were ‘in the deep end’, not ‘knowing how to bridge the gap’, when ‘everything goes out of the window’ because they experience ‘a clash between simulation and reality’ and it’s like they are ‘starting from scratch’. In terms of the transition itself, recent graduates and newly-registered doctors repeatedly referred to the ‘one day-next day’ scenario: ‘one day you’re not asked anything, and then the next day you get asked everything’, ‘one day you’re a 5th year student, and one day you’re a doctor’. The stark reality of the situation as summed up in terms of the difference between focusing on passing the placement (in their student role) and focusing on settling in with the team (in their F1 role). Overwhelmingly their talk

implicitly or explicitly focused on the issue of responsibility and how this became quite different overnight: ‘you go from no responsibility, to whole responsibility’. This issue of responsibility was also talked about by participants in the D_FP and CE groups: some felt that this was something that could not be taught to graduates, and thus they will always be unprepared in that aspect.

Within their narratives, participants in the FRTD group frequently talked about the many things that they did not learn as medical students that they needed to know as an F1 doctor: being prepared for the amount of work that they would have to do (including managing the high volume of paperwork), the level of multitasking required of them, learning who to ask and when to ask for help (including who to refer to) and understanding how the hospital works (which can be very different across hospitals). Working with, and dealing with, inadequate team members (including other healthcare professionals) was also mentioned frequently, along with being prepared for working unsupported since their seniors also rotated concurrently (Box 16, Excerpt 2). BOX 16:PARTICIPANTS’ TALK AROUND THE AUGUST TRANSITION PERIOD

Excerpt 1:

F_PPR_43: they do say don't go into hospital in August because you’ll die M_PPR_45: that's right don’t

F_PPR_43: no they do say that Several: ((laughter))

M_PPR_45: oh yes, yes

F_PPR_44: or at the weekends ((laughter)) M_PPR_45: or at weekends ((laughter))

F_PPR_43: quite a big- you know it's quite frightening- don't get ill F_PPR_44: yes, yes

F_PPR_43: you know- feed yourself in the house like F_PPR_44: yes, yes

F_PPR_43: you know, but don't go in to hospital

F_PPR_44: I mean, I used to feel quite sorry for the housemen you know…the newly qualified ones because there they were landed with all these patients

M_PPR_45: yeah, yeah F_PPR_43: yes

F_PPR_44: and not a lot of supervision…and trying to make decisions and then getting told off if they made the wrong decision ((laughter)) yeah

Excerpt 2:

“We didn't have any time actually following the job that we were going to do in the hospital… for instance, I didn't follow this job, and I wasn't in this hospital. So I didn't know how to use the system when I turned up, the computer system’s different. I didn't know where to go. A chest x- ray, for instance, now I'd go and give [it] to the person on floor 2, and that takes me 30 seconds to think, do, and take to them. On day-1 you don't know how to fill out an x-ray form, where to take

an x-ray form, you don't know who to speak to for an x-ray form, you don't know how to then check the x-ray form, and you don't know what to do with the x-ray form. So you know that’s just five things with the x-ray form. That alone, getting the actual x-ray and interpreting…another important thing that in general for junior doctors is this is our first day. We were new. We were brand new to this hospital and our SHOs and our registrars were also new, and all changed on the same day, which was a really dangerous thing to have done. A massive oversight by whoever decided that was the case, and really, really to be perfectly blunt, stupid of whoever decided it was a good idea to have all F1s, all CTs, all SHOs, all registrars, change on the same day because they were all in inductions, so we were on the ward with no senior help and no one. We didn't know who to call because they hadn't picked up their bleeps, so we had no way of contacting the right seniors, we had no way of knowing where they were, let alone who they were, what their names were, and we didn't know what we were doing to start with, let alone having the clinical

knowledge to be able to work with what we did…I think that was- that was worrying. But, yeah I think, otherwise…” [M_F1_28]

Excerpt 3:

“Just to add, with medical students throughout their curriculum and as they graduate as F1s they’re more prepared for practice because they have acquired more observational skills, their communication skills and they’ve learnt better, and seen the significance and the importance of actually listening to the patient and listening to what the patient has to say to help with the diagnosis, or to help relieve an anxiety.” [F_HCP_164]

S

A

 The August transition was discussed by all participant groups, with most narratives being coded ‘unprepared’;

 Some F1 participants cited the ‘all change’ on the same day in August as their biggest concern regarding patient safety;

 F1 doctors’ feelings of preparedness were facilitated by familiarity with the specific working environment and confidence in their training, particularly practical procedures,

communication and decision-making;

 F1 doctors felt unprepared for the step change in responsibility, the workload, the degree of multitasking, deciding who and when to ask for help, understanding how the hospital works (which varied by hospital) and dealing with underperformance of other team members;  The transition experience was stressful, with vivid descriptions of the abrupt shift from

medical student to the F1 doctor role and extensive use of metaphor;

 The PPR group’s perceptions tended to originate from the popular press and were unambiguously negative.

Having highlighted a range of viewpoints and experiences around the issue of preparedness for practice for ‘day 1’ of the August transition, we now turn to consider participants’ viewpoints and experiences of medical graduates over the first few months of becoming an F1 doctor.

4.4.4. RQ3: To what extent do recent graduates perceive themselves to be prepared for