| Summary: | Background: Several studies have shown that newly qualified doctors often feel unprepared to provide acute care, and that such feelings are a source of anxiety and stress. The main aim of this thesis was to explore how newly qualified doctors perceive and negotiate the complex challenge of assessing and treating acutely unwell patients in the early days of their professional practice. The thesis begins by examining preparedness in a local context and proceeds to explore preparedness in acute care throughout the UK. A variety of qualitative research methods are then employed to explore behavioural influences and patterns of error within acute care contexts. Methods: In the first instance, a questionnaire study was undertaken at the University of Edinburgh, involving feedback on preparedness for practice over three consecutive years from 2007 to 2009, against 13 major programme outcomes, from graduates and their educational supervisors. In order to gain a more global perspective, a systematic literature review synthesising work examining the perceived preparedness of UK graduates in acute care versus other General Medical Council mandated outcomes was then undertaken using five databases archiving medical, educational, nursing and psychological literature. Preparedness ratings in relation to each outcome were mapped to a novel generic rating scale to allow comparisons between studies. Six focus groups involving 36 clinicians were conducted and analysed using a constructivist grounded theory approach. The developing theory and relationships between emergent themes were refined and validated by further interviews with participants. Subsequently, 38 newly qualified doctors participated in high-fidelity simulated acute care scenarios. Each scenario was immediately followed by a debriefing which encouraged articulation of cognitive processing. Errors were identified and coded where possible using Reason's generic error modelling system (GEMS). Remaining errors were coded inductively using a modified framework analysis to discern further patterns within the data. Results: University of Edinburgh graduates consistently felt well prepared in consultation and communication skills but less prepared in acute care and prescribing. Educational supervisors felt that graduates were least well prepared in acute care and practical procedures. The literature search recovered 256 articles, of which 10 satisfied the inclusion criteria. These articles suggested that graduates perceive themselves to be the least well prepared in acute care and prescribing, and senior doctors and other healthcare colleagues perceive newly qualified doctors to be less well prepared in acute care than any of the other outcomes. Three broad themes emerged from the focus group data: cognitive challenges, roles and responsibilities and environmental factors. Exploration of the relationships between the themes led to the development of a conceptual framework. Using evidence from the simulated scenarios, corresponding debriefs and field notes, 164 of the 243 simulated scenario errors could be classified according to the original version of GEMS. A further 26 errors were coded using two novel categories: compound error and submission error. Multidimensional analysis involving both the amplified GEMS classifications and iteratively-developed key subject areas revealed specific patterns of error such as the propensity for rule-based mistakes relating to hospital systems. Discussion and Conclusions: This thesis adds to existing work which emphasises the complex inter-relationships between emotion, affect, decision-making and behaviour. It is the responsibility of the medical education community to ensure that newly qualified doctors are aware of the roles that these factors play in errors and adverse events. Emotional skills training, particularly with reference to dynamic, high-stakes situations, should form an integral part of basic medical training. Medical training and assessment structures currently emphasise and reward personal knowledge and academic attainment above collaboration and emotional maturity. In the drive to improve patient safety, a key component is to nurture doctors who understand human fallibility and who feel empowered to seek help, safe in the knowledge that they will not be deemed to have failed.
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