R ESULTADOS PARA EL C ONJUNTO DE T EXTOS A RGUMENTATIVOS Y D ESCRIPTIVOS

Assistantships were considered by P_GVT stakeholders to be an arena in which to “act up as a medical student”, to try out their future roles and to translate theory into practice (see Excerpt 1, Box 11 on page 83). The perceived effectiveness of student assistantships was discussed across all participant stakeholder groups except for the PPRs (with 49 PIN/GINs (2.8%) being coded to this). The majority of data comes from the F1s

themselves. All stakeholder groups who discussed this issue highlighted the effectiveness of student assistantships (with 35PIN/GINs (71.4%) coded as effective, 10 (20.4%) coded as ineffective and 4 (8.2%) as complex34_).

In terms of effectiveness, assistantships were seen as being pro-active forums, essential for students’ learning of how things work on the ward, for seeking out practice of practical skills (such as venous blood sampling and inserting peripheral venous cannulas: Box 11, Excerpt 2), affording the opportunity to follow the patients’ journey and enabling them to

see the consequences of clinical decisions and treatments. Some F1 participants commented on how they felt that there was only a ‘slight jump’ from assistantship to their F1 year in terms of responsibility. When they were an ‘F0’35 _{they felt they always had someone to ask, whereas by} implication, F1 doctors are less supported. Aside from this support, as an F1 they felt it was ‘business as usual’ as they already understood how the system worked and what would be required of them once they became an F1 (Box 11, Excerpt 3). This view was echoed by participants in the D_FP group who believed that assistantships reduced stress in F1s when

34 _{Complex narrative comprised aspects of effectiveness and ineffectiveness with no clear outcome specified} 35

The assistantship phase of their undergraduate degree was often referred to as the ‘F0’ year.

BOX 12:ASSISTANTSHIPS:FACILITATING AND INHIBITING FACTORS

Facilitating

Personal Students’ confidence, proactivity, resilience and approachability.

Interpersonal Leadership, positive role models, wider team. Cultural/systemic Knowing protocols. Inhibiting

Personal None cited. Interpersonal None cited.

Cultural/systemic Not knowing protocols, technology.

starting their new job due to their increased confidence in undertaking practical skills as well as feeling part of the team (Box 11, Excerpt 4).

However, a few F1s talked about their experiences of assistantships very differently, and alongside other stakeholders, they felt that assistantships were not always effective in preparing them for practice. While assistantships frequently prepared some graduates for practice, other graduates felt it was sometimes left to chance in terms of dealing with challenging or difficult situations; such situations were often left for more experienced doctors (e.g. inserting a urinary catheter into a patient with an enlarged prostate gland), with little opportunity for teaching these challenging procedures.Thus trainees highlighted a lack of responsibility within their assistantships with no opportunities to work on-call or during out of hours shifts (Box 11, Excerpt 5), leaving some feeling sheltered and calm during their F0 year, a far cry from the disturbance of the F1 ‘ocean’ (Box 11, Excerpt 6). Other stakeholders talked about assistantships in terms of the difficulties in students being fully included as members of the multidisciplinary team, particularly when teamworking comprised a multitude of interrelated facets and not just patient care: aspects such as the nuances of communication, leadership and peer-support (Box 11, Excerpt 7).

Finally, participants in the CE group talked about the varying nature across assistantship

programmes. Some students had more of an opportunity to be proactive and part of the team than others for various reasons: including medical school, placement setting, and student characteristics such as being proactive (Box 11, Excerpt 8). All participant groups referred to facilitating and inhibiting factors that contributed to the effectiveness of assistantship programmes (see Box 12 on page 82). Personal factors were cited more highly as being facilitating than interpersonal or cultural/systemic factors with students’ proactivity and confidence being commonly mentioned. Leadership, positive role models and the wider team were also facilitating factors, along with students knowing the explicit rules and procedures regarding ‘when X happens’. Conversely, not knowing the protocols and not having access to computer passwords were cited as inhibiting factors.

BOX 11:PARTICIPANTS’ VIEWS AND EXPERIENCES OF ASSISTANTSHIP PROGRAMMES

Views of Assistantship Excerpt 1:

“and then in the final year, preparation for practice when students are really doing shadowing* for most of the time, is the chance really to make sure that that knowledge does translate into day-to- day activity” [M_P_GVT_112]

Assistantship Effective Excerpt 2:

“I think that assistantship was really good in terms of you got to actually do the job of a doctor without actually having all the exams around it … which was really useful … I was on a respiratory ward so I got to do about 40 ABGs ((arterial blood gas sampling)) or something…which you don't really get to do that many ABGs as a med student so it was actually really useful, so assistantship was really good for that…I started at the end of 4th year just cannulating people…by the time you get reasonably good at cannulating they'll start letting you cannulate everything and then

everything in sight, so you start of at the antecubital fossa and then you work your way down to the hands and then by the time you get to F1 I'm already cannulating people's feet, whereas some people don't do that until their SHO (Senior House Officer) level” [F_F1_19]

Excerpt 3:

“We had a patient who came in with epididymo-orchitis and the cultures were positive for various different things and the bug was sensitive to different drugs and we wanted to send him home, but if he was on IV antibiotics we weren’t going to send him home with that, so calling up microbiology

and asking them ‘what can we switch him to?’ and then knowing that you had to ring rapid

response if you had to send him home with IV antibiotics. I knew. I was prepared for that because I had done it before on the wards quite a few times when I was a fifth year, because that’s the kind of things they let you do just for you to get used to- so I knew how to call rapid response because I'd done it before and I knew what to say to the microbiologist, whereas some people might not have been prepared in that situation” [M_F1_36]

Excerpt 4

“…giving the students meaningful things to do in a safe way…It’s good for the students. It’s good for the patients. It’s good for the hospital…it kind of wins all the way around…making them being in one place with the same clinicians and seeing the role modelling of a well operating team of professionals, of different health care trades working together, that imprints on them and then they hopefully go out and say “yeah I can to that” [M_D_FP_113]

Assistantship Ineffective Excerpt 5:

“I mean the majority of our last couple of years were on placement, weren't they, but you don't get given- well we didn't get given any responsibility as a student. You're there to shadow. You're there to watch. And you get to clerk patients you don't do the actual job even on our

assistantship…where that’s what you’re meant to do. You don't really. Like they'll say “oh can you fill this blood form out?” or “can you do one or two things?” but you don't actually get given the chance to be in charge of all the patients and know about all of the patients. On-calls again. I've never been forced to do an on-call shift. Whereas I think we probably should've to give us experience. So yeah definitely not enough responsibility as medical students, and I don't think it should come during the first few years, but during the fifth year” [F_F1_27]

Excerpt 6:

“when you were a student on the ward you were just given a little- you were almost kept in a little harbour where there was no disturbance whatsoever, and then once you become an F1, you're released out into the ocean and you're hit by big waves, and there's no sort of calmness

anymore…as a medical student you've always got the great barrier of ‘sorry I'm a medical student’… I used it up until the last day of the fifth year…everyone does “sorry…I'm a medical student, I'm off”…there's no transitional period. I know there's supposed to be this transitional period with the student assistantship, but even that is still sheltered” [M_F1_22]

Excerpt 7:

“we attempt to provide them with exposure…an opportunity to attend multi disciplinary team workings, and certainly within our assistantship there is an issue about observing a multi disciplinary team at work…you’re the outsider looking in. Its only when you actually become embedded within the team that you suddenly realise how teams work…I think we probably could invest more time in ensuring that these individuals become part of the team rather than an addition…sitting on the periphery…multi disciplinary teams that they observe are very much based around service, and there’s an agenda, and things to be covered…not just about the delivery, it’s about the peer support, it’s about the by-law of the understanding and the communication within a team…it’s about understanding the dynamic and it’s also about how teams are led” [M_D_FP_165]

Assistantship Variable Excerpt 8:

“F_CE_159: Well this F0 did answer the bleep F_CE_157: Did she?

F_CE_157: Well that’s great if you can be in a team and you can have a bit of that an element of that responsibility supervised I think that would be really helpful

F_CE_159: They were quite prepared to get like- she didn’t go for lunch if we didn’t go for lunch F_CE_157: That’s good but that would probably- some people wouldn’t always get that

F_CE_159: Yeah”

NOTE:*This participant uses the term shadowing here, although they are referring to the longitudinal

assistantship programme. **Antecubital Fossa: Triangular cavity on the anterior view of the elbow;

Arterial Blood Gas (ABG): Blood test performed using blood from an artery to measure the amount of

oxygen and carbon dioxide in the blood; Cannulation: Insertion of an indwelling plastic tube (cannula) into a patient’s vein to allow fluids to be infused into the vein; Epididymo-orchitis: Inflammation of the

epididymis (a tube that connects the testis to the vas deferens) and testicle.

S

(P

2&3):

 Student assistantships were widely discussed, particularly by F1 doctor participants, with far more participants considering their experience effective than ineffective;

 Student assistantships were perceived to smooth the transition to F1 doctor, by enabling students to find out how things work on the ward, practice practical skills, feel part of the team and follow patients’ journeys;

 The degree to which participants could engage with opportunities, take on responsibility or feel part of the team was variable, however, and affected by multiple factors, including personal characteristics of the student (e.g. confidence), interpersonal factors (e.g. team leadership) and cultural / systemic factors (e.g. knowing protocols).