Even though this research project did not show that the environment was a major contributing factor which supports trainees, the author still thinks that organisational learning is the most powerful tool to combat change and improve service delivery in the NHS as a whole. It remains the ideal, with each local community or specialised area contributing something to the organisation as a whole. The initial aim of this research project was to investigate whether the intensive care environment was the main factor supporting and influencing junior trainees during their intensive care rotation. The idea was that ‘organisational learning’ which occurred at a local level was indirectly contributing to doctors in general and especially the junior doctors’ function within the National Health Service (NHS) in general.
‘Organisational learning is a process of increasing the capacity for effective organisational action through knowledge and understanding’ as described by Fiol et al 1985and Senge et al 1990 [4,5]. It is a process whereby knowledge is learned from action and reflection and implementation of new skills and training is made richer and more effective because it is generated at ground level by the team itself. It is a living, dynamic process of self-evaluation, reflection and reimplementation of methods which improve outcomes by improving staff training and support. As individuals (trainees) get experience, they change rotations, new information is obtained, policies change, the best practice remain and is shared with the unit and organisation as a whole.
Argote et al, 2000 stated that ‘Knowledge necessary to carry out these routines is stored in many different forms and locations, including procedure manuals, physical equipment and layout, and in individual minds.’ This statement resonated in the author’s thinking and after reflecting on the interviews it is postulated that Argote is describing the ‘culture’ of the organisation and how this culture facilitated learning on the shop floor.
What does this have to do with trainees’ support in critical care? From the interviews the trainees had no understanding of the influence of the organisation on their learning or that they brought with themselves important organisational lessons from previous rotations. They outlined three main factors which they perceive as important in their support on the intensive care unit; the author called it the ‘tripod of critical care support’.
Critical care support
Critical care support is akin to a tripod with the junior doctor at the apex, with its base comprising of three components; the nurses, consultants and lastly the intensive care environment. These three components combine to form the ‘critical care culture’ which trains, nurtures and support critical care doctors. It is evident from the trainees’ interview that the presence of a critical care culture is a palpable entity with the nurses at the centre reinforcing the status quo and the trainees need to be on the nurses ‘good side’ in order to maximise and enjoy their critical care rotation.
Nurses’ support role to junior doctors
In a survey by Lambert et al, 1996 conducted over 4 years into newly qualified doctors by it was found that the majority of respondents felt that they were strongly supported by the nurses and senior doctors but not by the organisation as a whole . However, 22% of respondents felt that they were not adequately trained for some of the tasks they were asked to perform. This survey was conducted among the foundation one trainees and maybe applicable to the trainees this unit. It is interesting that the support that Lambert’s trainees felt were similar to that of the previous survey conducted in the 1970’s with the main difference being that of discontent with the organisation as a whole (NHS). There is indeed a gap in training these new doctors’ issues such as shift work patterns, changing professional roles, European working time directive reducing working hours all add to the tension experienced by this group of doctors. The basic skills such as team working, communication, personal development which is so necessary to this group of future health professionals is less focused on as there remains a balance between educational needs and service provision. The nursing group seems ideally placed to provide some help in these areas as their clinical roles are changing with the adoption of more junior doctor roles in clinical practice, the difficulty that remains is, how will we implement this in practice?
‘Teaching could occur either in terms of informal role modelling or more formal classroom and or ward-based sessions about speaking with patients and their families’Vallis et al 2004 and a role modelling structure for team working by observing and reflecting on the practice witnessed by the nursing fraternity .
Wall and Mc Aleer, 2000conducted in depth interviews of 19 consultant teachers and junior doctors in the midlands and found that the most important traits that a good consultant teacher should have were :
‘The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee’s learning needs’
He recommended that the deanery should focus on these areas in order to deliver more effective trainee teaching and support. What is the junior doctors’ perception of support by consultants? It is not good, in an analysis of critical incidents by Calman and Donaldson1991, they found that;
‘There was a need for effective supervision of the house officer with feedback on performance. An induction/orientation period is necessary; there is evidence that a proportion of house officers need additional experience of practical procedures; house officers often have difficulty in setting priorities and they have little experience, prior to qualification, of organizational skills; during the year they are very busy with little time off. They perceive a lack of support from senior staff to help with personal problems and career guidance; they are conscious that communication skills are of great importance and would like additional help with this’ .
This damming report on the reality of trainees’ support was unnerving to us as educators in the profession but I think things have changed for the better today. Consultants are now better trained as teachers and the roles of clinical and educational supervision have been more formalised and structured. In my interview, the role of the consultant was perceived as an all-encompassing one. The trainees did not separate the consultant’s supervisory role from that of educational supervisor. It seemed that they valued the clinical supervisory role, that is, on the shop floor more than the educational supervisory role. The difference between the two is small but significant; the clinical supervisor supervises and trains these junior doctors in their daily clinical tasks while the educational supervisor oversees training during the rotation in the specialty and coordinates or liaises with the college tutor. I think that it is a good thing that the trainees had not highlighted the separate consultant roles but amalgamated these roles in one. In reality, a consultant can function as both an educational and clinical supervisor to any allocated trainee so that the trainees may not perceive much difference the trainer’s role.
Intensive Care Environment
‘Workplaces are arenas of activity in which socio-culturally determined practice occurs, Billett 1998 and are one of the domains through which the social is ordered Edwards and Nicoll 2006’ [12,13]. The Intensive care environment within the hospital setting is a complex environment with complex interactions of knowledge from different professionals with vastly different roles and it is how the trainees participate in this working relationship which determines how much and how well they learn. ‘The workplace as a learning environment is understood as a complex negotiation about knowledge use, roles and processes, affordances, and engagement Billett 2004; Unwin and Fuller 2003 [14,15]. It is vital to recognise as an educator that workplace learning is not simply the transfer of theory to practice but the assimilation of knowledge, processing by the trainee in the community and performance of skills or retention of information. The environment or as my research project showed, the ‘intensive care culture’ reinforces knowledge within its structure so that knowledge transfer can take place.
What are some factors which limit knowledge transfer?
Broad and Newstrom, 1992found nine barriers to knowledge transfer, with the lack of reinforcement being the most significant barrier to transfer . The complex and unfamiliar critical care environment helped to keep the trainees focused on daily tasks and reinforced all the information which they were exposed. The fact that they were anxious about their environment and felt as if the ‘did not belong to the community’ served to positively reinforce their ability to function in this environment and not take things or situations for granted.
The trainees also stressed that they were most anxious about ‘making decisions’ about critically unwell patients even at their very junior level despite reassurances that someone more senior was close at hand.Johnson, 2002 showed that a key factor in learning transfer is the opportunity for trainees to apply what they have learned to their jobs, therefore the only way to allay the anxiety was for the trainees to actually work on the ‘shop floor’. The author initially thought that the induction was useless as there was still so much anxiety expressed by the trainees but realised that they felt that their lack of skills, insight into the environment and knowledge made it seem as if they did not believe me during their induction.
Comments such as;
That’s what I felt because everything is new; I’ve never been dealing with 9 or 8 critically ill patients. They ask me questions regarding ventilator settings which they are not familiar with, so I thought that I need to be a difficult rotation.
These sentiments were too common despite assurances at the induction that they were in a junior role with senior support only up the corridor and that airway skill was not need on this unit.
Implication for practice
There is a move for reduced number of doctors in training and we are seeing a 10% reduction in training number as workforce planning streams have predicted that there are too many doctors in training. ‘In a report by Health and Education National Strategic Exchange used data and calculations by the Centre for Workforce Intelligence to estimate the supply of trained doctors in future years. It has found that by 2025, when students entering medical school next year will become fully qualified, there will be an oversupply of more than 10,000 trained hospital doctors. The 2 per cent cut in training places is expected to have an impact from 2025 onwards’ (HJC 2012). As a result, we will have more junior staff and maybe even nurse specialist working on the ICU performing junior doctors’ role. It is imperative that we focus our attention on trainee support so that we can effectively cope with the changes that are coming to the workplace. The author thinks that we need structure and formalise the input by nurses in training by formally incorporating their feedback on trainees as part of their module feedback. Also, as part of the induction the trainees should be given a specific outline of their roles and have a trainee at their level actually go through a day on the ICU, this will help to ally their anxiety some more.