Exploring the views of second‐year Foundation Programme doctors and their educational supervisors during a deanery‐wide pilot Foundation Programme

Abstract

Aim

To explore the views of second‐year Foundation Programme doctors (F2s) and their educational supervisors taking part in a deanery‐wide pilot Foundation Programme, in order to gain an understanding of their perceptions of the available learning experiences, support and supervision.

Methods

20 semi‐structured interviews were undertaken with randomly selected F2 doctors and educational supervisors participating in the deanery‐wide pilot Foundation Programme.

Results

F2 trainees received appropriate and sufficient support and supervision from a variety of sources during their placements; however, it was believed that additional training of educational supervisors was required. Trainees reported some problems with the perception of the role of an F2; further understanding of the purpose and role of the F2 programme is required at trust level. The portfolio was viewed positively as a record and a learning tool, but was thought to be too bureaucratic. Trainees believed that it was more beneficial to their careers to take part in a foundation programme as opposed to a traditional senior house officer post, but both trainees and educational supervisors expressed some concerns about the generic nature of some skills F2s were expected to acquire.

Conclusions

This evaluation has highlighted successful aspects of the Foundation Programme, particularly with regard to the level of support and range of experiences provided for trainees. Issues of concern to both trainees and educational supervisors have been identified, which require additional understanding.

In the document Unfinished business,¹ Sir Liam Donaldson, Chief Medical Officer, proposed the creation of a planned 2‐year Foundation Programme after graduation. Subsequently, the document Modernising medical careers² focused on the implementation (August 2005) of the proposed 2‐year Foundation Programme in more detail, defining policy and outlining the effect on specialist registrar training and the early stages of the career as a consultant.

In August 2004, the Mersey Deanery established 242 second‐year Foundation Programme (F2) posts in a deanery‐wide Modernising Medical Careers prototype. A learning portfolio, including both formative and summative assessments, was developed locally for the prototype. It included all the assessment methods (mini‐clinical examinations, direct observation of practical skills, case‐based discussions and 360° assessment) expected to be integral elements of the national learning portfolio that was formally introduced across the UK in August 2005 for all Foundation Programme doctors.

A qualitative study was designed to explore teaching and learning during the deanery‐wide 1‐year prototype, based on the experiences of F2 doctors and educational supervisors. Apart from informing local educators on the deanery‐wide prototype and the introduction of new assessment methods, this study also informed those interested in the development of Foundation Programmes across the UK. The evaluation considers several aspects of the Foundation Programme, specifically supervision, the role of an F2, assessments and the portfolio.

Methods

The deanery‐wide F2 prototype covered 10 trusts across Merseyside, and surrounding areas:

• Countess of Chester Hospital NHS Trust

• East Cheshire Hospitals NHS Trust

• Mid Cheshire Hospitals NHS Trust

• North Cheshire NHS Trust

• Southport and Ormskirk Hospitals NHS Trust

• St Helen's and Knowsley NHS Trust

• The Royal Liverpool & Broadgreen University Hospitals NHS Trust

• The Royal Liverpool Children's NHS Trust

• University Hospital Aintree

• Wirral Hospitals NHS Trust

In all, 242 posts were established with each F2 undertaking triplet rotations of 4 months' duration. Members of the research team (MO'B, JB and IR) attended F2 education sessions at each trust where the nature of the study was explained to trainees. Written information about the study was provided and all F2 post holders were given an opportunity to take part in this study. Informed written consent to participate was obtained in line with the requirements of the local research ethics committee. Twenty F2s were randomly selected, using a table of random numbers, from the list of 147 doctors who had given their consent to participate in a semistructured interview. Of the 20 randomly selected F2s, 15 agreed to take part. Of the 154 educational supervisors, participants were selected in the same random manner. Written consent was obtained from 18 educational supervisors (EdSup) however, work commitments reduced the number available for interview to five.

It is important to define the different roles of an educational and a clinical supervisor. An F2 may work with or be trained by several consultants or general practitioners in a team. These may act as clinical supervisors. The clinical supervisors have an important role, but they do not set objectives or assess the F2's performance in a formal way. The role of an educational supervisor is different. At the start of their post, F2s are allocated an educational supervisor who sets objectives and overviews the assessment of the trainees. However, each trust operates a different supervisory system. Educational supervisors in some trusts oversee the education and training of the F2s for the whole 12‐month period, whereas educational supervisors in other trusts oversee the education of F2s for the duration of one triplet.

MO'B and JB conducted the F2 interviews, and IR conducted the educational supervisor interviews using a semistructured interview schedule. The interview schedule was developed to obtain feedback from the trainees and educational supervisors, which would consider specific issues that were regarded as priorities in the deanery, specifically, to comprehend perceptions of trainees on their learning experience and understand the support and supervision that they had received. Arrangements were made to conduct interviews at a mutually convenient time and location. Of the 20 interviews, 14 were conducted face to face and six were conducted over the telephone (interviews lasted between 15 and 30 min). It was recognised that some participants may have concerns regarding recriminations if they were to make negative comments; however, to facilitate free and open comment about their experiences, all participants were assured of anonymity and confidentiality regarding their remarks. Interviews took place between May and June 2005, during the time of the third triplet, so that respondents could recall their experiences from the whole prototype year rather than from one post in isolation.

Nineteen interviewees gave permission for the interviews to be tape‐recorded. One interviewee did not give permission, so extensive notes were taken by the researcher. The tape‐recorded interviews were transcribed verbatim.

The transcripts were subjected to cross‐sectional code and retrieval analysis³ independently by two of the authors (MO'B and JB) before comparing findings and agreeing on the emerging themes. This process reduced the likelihood of introducing bias at the analysis stage and contributed to rigorous analysis of the data.⁴ QSR Nvivo version 2.0 qualitative data analysis software was used to facilitate the analytical process.

Results

Data analysis generated several relevant themes.

Support for teaching and learning

The trainees were generally satisfied with the type and amount of support they received during their training. Support included activities such as regular meetings with supervisors, setting objectives for the year, career advice, discussion supervision and observation during practical procedures, informal training in clinic, theatres and on ward rounds, and the provision of good learning opportunities. Support was available from a variety of sources, which was appreciated by the trainees.

It was the whole team who supported us right from the consultant. Obviously consultants are not available all the time, so when you have a doubt or when you want to discuss a case you approach your immediate seniors, which are usually the staff grades or the SPRs [specialist registrars] and they always supported me and they always guided me and in certain complicated procedures they supervised me. (Dr2)

Although educational supervisors recognised the requirement for them to support the trainees, there was acknowledgement from one “whole‐year” supervisor that guidance was available from other sources as well.

I suppose the whole team offers support in certain respects, because I am their educational supervisor for the year, or I am somebody they can come to for the whole year; the others [rest of the team] are more for just when they [F2s] are here [in the department]. (EdSup1)

Trainees thought that they had been taught well as a result of this support. Consultants monitored and supervised the trainees to ensure that they had developed as much as possible. Although they may not always have felt in need of support, the F2s were aware of its availability.

I have been pretty happy with a lot of the support I've got really. I've always felt there's people I can go and talk to and ask stuff about, but generally I am an independently minded person and have been able to get on with it by myself really. (Dr171)

F2 trainees reported benefits from having educational supervision, which included receiving career advice, setting objectives and assessing educational needs.

I discussed my educational needs and objectives were set how we would achieve that, this concept of educational supervision was very good, it's worked out very well. (Dr2)

He [educational supervisor] has been very helpful … telling me how to approach things, even clinical procedures. (Dr214)

He [educational supervisor] gave me lots of career advice as well, because at first I was very confused about what to do. (Dr209)

Educational supervisors were keen to support and guide trainees in various ways to enhance the learning experience.

I love having a chat with [them], asking if they have got any problems, telling them if I've perceived any problems and giving them as much help as I can. (EdSup2)

I want people to get as much out of the job as possible. (EdSup3)

However, not all trainees reported positive experiences; it was the commitment of some trainees that acted as a catalyst for ensuring that their educational supervisors engaged with them.

To complete the portfolio has required a lot of pro‐activity and persuading my educational supervisors to complete the documentation. (Dr6)

It should be noted that the responsibility to complete the learning portfolio lies with the F2 and the whole process relies on the motivation of individual trainees.

Perception of the F2 role

Six F2s commented that there were problems in how their roles were perceived by their colleagues. There was a feeling that the Foundation Programme was poorly understood in the trusts, and specifically that the roles of F2s in particular were misunderstood by all grades of staff. Trainees reported that others often regarded F2s as less skilled than they actually were.

I was on a ward round with a Registrar and I answered a question about something and he said “oh, I can tell you are not an F2 then”. So I don't know if that was supposed to imply that F2s aren't good enough. (Dr5)

It was also thought that some consultants were reluctant to allow F2s to perform tasks normally undertaken by traditional senior house officers (SHOs).

… a lot of the medical consultants didn't want F2s discharging patients … but they are a bit stupid because 1st year SHOs have always done that. (Dr1)

Many healthcare staff considered the F2s to be more junior than they actually were, which resulted in many F2s regarding themselves as being ranked somewhere between a house officer and an SHO.

… there are a lot of people that perceive us as being glorified house officers, from the nursing staff, right up to the consultants and to our peers as well. (Dr171)

Normal SHOs are doing normal jobs, PRHOs are doing their PRHO jobs and F2s are in between these two, there is some lost integrity. (Dr3)

Some F2s also thought that even their educational supervisors were unclear of what was required of an F2 trainee.

I think some educational supervisors are not aware of the nature of the F2 job and the requirements or the criteria that they need to fulfil with them. (Dr4)

Some trainees thought that they were regarded as not being different from traditional SHOs, and many perceived themselves as SHOs in all but name.

I'm considered a normal SHO … I've just slotted into an existing SHO slot and I've just been able to behave exactly like one. (Dr229)

You are doing something else, normal SHOs doing something else. (Dr3)

Modernising medical careers aims to ensure that trainees receive regular formal training; trainees reported receiving more formal training than colleagues who were SHOs.

I've had extra teaching along the way … and a half day's teaching once a month. (Dr229)

We are allocated an hour a day of teaching. (Dr141)

One trainee commented on a lack of distinction between the roles of an F2 and an SHO, and as a result was concerned about the potential for unrealistic expectations of F2s if they were to be compared with more senior SHOs.

Here, people do not differentiate between the F2 and the medical SHO … but the nature of the [F2] job, the level of competency and the expectations should not be compared to the SHO … because some of those SHOs have their exams and some of them have got previous experience … the expectation and the jobs they need you to do, it is supposed to be at the level of the F2, it is not supposed to be at the level of the SHO … we are only in a junior training post. (Dr4)

The Foundation Programme

F2 trainees expressed views on how beneficial they thought it was to undertake the Foundation Programme as opposed to a traditional SHO post. As was the case with Beard et al,⁵ many trainees regarded the Foundation Programme as successful, in that they were given the opportunity to sample a broader range of specialties.

I'm glad I did it because lots of my friends did regular SHO posts, but I think I was quite lucky to do this one because I had lots of experiences and I learnt quite a bit, probably more than I would have if I'd done a regular six month post. (Dr209)

Although a recent study⁶ reported that trainees did not find the Foundation Programme beneficial in terms of making career choices, our findings support the assertion of Beard et al⁵ that participation in the Foundation Programme could inform and enhance future career choices.

It has worked quite well for me because it has allowed me to get some anaesthetic experience and I've decided that I'll do anaesthetics as a career. (Dr171)

Comments received from some trainees showed that although they recognised benefits to undertaking the Foundation Programme, they had some concerns about some of its aspects, primarily the level of generic skills they were expected to acquire.

I think some things are good about it but I'm not sure about having people watch you do skills that you really should have gained in medical school, or you have been doing since you have been a house officer. (Dr143)

The teaching of generic skills is really a bit too late … you should establish that as a student or a PRHO really. (Dr141)

The deanery‐wide F2 pilot programme was based on three placements of 4 months' duration. Opinions of trainees were divided regarding the ideal length of time for placements; further work is required to identify whether this is specialty specific.

I think that four months is fine. (Dr141)

I don't know whether 4 months or 6 months is better, because I feel that at 4 months you are at the stage where you are starting to feel quite confident and it would be nice to have another 2 months to build on that, when you get confident I think that you learn a bit more. (Dr1)

They are good for getting experience, the problem is when you are there for 4 months you never really get to master anything, you are a constant beginner for a lot of the time and you are not often put in positions of responsibility. (Dr171)

Competency‐based assessments

Trainees generally regarded the concept of assessment positively, but there were criticisms of the format of some assessments, which were perceived by some as time consuming and of limited benefit.

I think having a final assessment at the end of each post is good, but how it is actually done in terms of mini CEXs [clinical examinations] and case‐based discussions, the consultants sometimes don't always get a chance to observe you doing certain things, or they know already that you can do it and it just seems more paperwork. (Dr143)

I think that it is very long winded, takes quite a long time and I'm not sure how beneficial that is. (Dr229)

Trainees identified that completing a learning portfolio had advantages; it focused their thoughts regarding what they hoped to achieve during each placement and provided a record of their achievements during the year. There was concern that maintaining it could be time consuming and the generic nature of the assessments might not adequately evaluate certain placements.

I think my portfolio is a great gift because I've got a portfolio that is full of information that I can show to everybody and tell that I have done a full year with very close supervision. (Dr4)

It is very useful, it has made me work a lot harder than my other friends who are not F2s because they have no pressure in terms of getting procedures signed. (Dr209)

These findings echo those of Beard et al,⁵ who reported that most trainees regarded a portfolio as useful but some were critical of a lack of specificity.

Educational supervisors were generally satisfied with the concept of training being documented, but they too expressed concern about the bureaucratic and generic nature of the portfolio:

I think it is a bit … bureaucratic … in terms of waste of paper … a lot of duplication and such basic stuff, tick this box, cross that box, sign this, date this. (EdSup4)

The portfolio is fine … [but] I think we need a bit more direction. (Edsup5)

I think some of it has been quite useful … the whole thing is just so generalised. (EdSup3)

Conclusions

This exploration of the views of F2 doctors and educational supervisors about the pilot Foundation Programme in the Mersey Deanery identified several important issues and provided an invaluable insight into the learning experiences of trainees. It has highlighted successful aspects of the Foundation Programme, particularly with regard to the level of support and range of experiences provided for trainees. The trainees received good levels of support and direction from colleagues from various departments. Some believed that the adoption of a 4‐month placement rather than the traditional 6‐month placement provided the opportunity to sample a broader range of specialties than traditional SHOs were able to, which may be beneficial when making career choices. The Foundation Programme introduced the requirement that doctors at this stage in their career be subjected to workplace assessment of their clinical and professional competence, and to achieve the same generic clinical and non‐clinical competencies as measured against the standards of competence set in the curriculum. The participants viewed the concept of assessments favourably and regarded it as a beneficial component of the Foundation Programme; however, the criticisms regarding the generic nature of assessments made by both trainees and supervisors should be noted and dealt with. As reported by Beard et al,⁵ trainees were generally enthusiastic about the F2 year and regarded it as an overall good experience; the lack of understanding about the programme by others, including some educational supervisors, was a cause for concern. Problems with perception of the role of an F2 by other colleagues including consultants, registrars, SHOs and nursing staff were apparent, and could result in confusion regarding their expectation of F2s. This has also been reported in another study,⁶ which found that nursing staff and colleagues perceived F2s as “essentially equivalent to ‘traditional' SHOs”. Despite a deanery‐wide information programme before starting the pilot programme, this problem may have resulted from a poor understanding of the Foundation Programme. It highlights the need to ensure that before implementation, such major changes to working practice are supported by appropriate training for all concerned. The Mersey Deanery initiated a range of additional training sessions before the August 2005 intake to solve this problem. A series of workshops for educational supervisors also provided training in using the portfolio and additional guidance on the completion of assessments so that educational supervisors are better equipped to support Foundation Programme trainees. As recommended by Kilroy and Southworth,⁶ specialist registrars, SHOs and staff grades should have some form of cascaded training so that they are aware of the Foundation Programme and assessment processes, even if they are not directly involved in assessing the trainees. We would also suggest that all healthcare staff who work with F1 and F2 doctors are provided with training regarding the Foundation Programme and the role of trainees, so that they are aware of what is expected of doctors at this stage in their careers.

This study has certain limitations, particularly with regard to the low level of participation by educational supervisors. This was unfortunate, but was primarily a result of workload commitments. Comments made by the educational supervisors did have congruence with each other and with comments made by many of the trainees. We intend to repeat the study with the current F1 and F2 cohorts to evaluate and compare teaching and learning experiences of the trainees as the Foundation Programme develops.

Abbreviations

F2 - second‐year Foundation Programme

SHO - senior house officer