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Fieldnotes: Experience and lessons from the Anaesthesia Training Programme in Ireland

Authors: Sheena Durnin, Deirdre Bennett, Rebecca Fanning, Patricija Ecimovic, David Moore, Shelley Ross and Josephine Boland Date: 30 September 2016

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I do not have an affiliation (financial or otherwise) with a pharmaceutical, medical device or communications organization.

College of Anaesthetists of Ireland •  Funding for the research study •  Conference support

Presenter: Dr Josephine Boland Director of Medical Educaiton College of Anaethetistis of Ireland

1.  Context 2.  Research study 3.  Selected findings 4.  Lessons learned for the next phase 5.  Conclusions

Need for �  a 'culture shift’ �  assessment of trainees’ clinical performance �  constructive feedback �  support for struggling trainees “Safe and effective clinical learning cannot take place without feedback; and providing feedback is a critical competency for clinical teachers”.

CBME Framework

: �  Quality of patient care �  Reduced 6-year programme �  EWTW directive �  ‘Your Learning Counts’ �  Learning from other contexts

Focus on feedback

CBME Framework

Brown N, Cooke L. Giving effective feedback to psychiatric trainees. Adv. Psy. Treat. 2009;15(2):123-8.

�  10 weeks �  Four hospitals �  Trainees �  Tutors �  Consultants

Informed by:

�  Brief summary of an experience/event in a clinical setting �  Initiated by a trainee or consultant �  Feedback from consultant �  Reflection/action points by trainee �  ‘Low stakes’ in nature

�  Part of a collection of evidence �  May contribute to progression decisions/remediation plans.

Durnin S. (2006) ‘Evaluation of a Pilot Study of Fieldnotes in Anaesthetic Trainees in Ireland’ Thesis submitted in partial fulfilment of the Masters in Clinical Education, National University of Ireland Galway

� Evaluate the feasibility and acceptability of Fieldnotes to trainees and tutors

� Audit the domains and competencies recorded by Fieldnotes

�  Inform the planning of a national launch of Fieldnotes by the College

Research Design �  Pragmatic �  Sequential �  Mixed methods

Methods �  On-line questionnaire �  Semi-structured interviews

Data analysis �  Content analysis �  Constant comparison approach.

Participants •  Trainees (51) •  Consultant Tutors (4)

"So it’s pretty much on an ad hoc (basis) really, you may

get feedback on a particular aspect of your

performance but that would tend to be if something had

gone really, really well. Or something had gone really,

really badly"

(TR16S).

Incentives for Change

•  Increased feedback •  Quick and easy to complete

Innovation Itself

•  Empower trainees to initiate feedback

Individual Professional

•  Increased collaboration Social Context

•  Evidence for decision to progress Organisational Context

“It captures that moment that might be otherwise lost. So you capture something, you do it instantly and then it’s done dusted, gone then we move on. " (CT3).

◦  2 -10 minutes to complete a Fieldnote ◦ Some prompted a prolonged discussion.

◦  "So… I haven’t used Fieldnotes often - probably because it’s not compulsory … But I had liked the times that I have used Fieldnotes. I did actually think that it was useful" (TR2S).

◦  "I would say I probably have gotten about a quarter done that I have attempted to initiate" (TR1S).

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Barriers to Change

•  Issues with paper-based format Innovation Itself

•  Trainee & Consultant reluctance to engage

Individual Professional

•  Feedback culture •  Time & service pressures Social Context

•  Lack of direct consultant supervision •  Consultant training

Organisational Context

� Need for further training � CPD credits for consultants � Mandatory minimum no. for trainees � A Smart Mobile Application

� The powerful discourse of ‘assessment’ ◦ Assure trainees of the ‘low stakes’ ◦ Revise the language of assessment �  ‘Feedback Reports’

� Use Fieldnotes where they add value ◦ Non-technical skills/professionalism ◦ More modest expectations (min. no.)

� EPAs in ◦  Vascular Access ◦  Managing Pain in Labour ◦  Pediatric Anaesthesia (ASA I-II)

�  ‘Orientation’ of tutors and lead trainees � Mandatory min. no. of reports

� Communicating the message

Direct Observation of Procedural Skill (DOPS) Fieldnotes

Case Based Discussion

DOPS

Case Based Discussions Fieldnotes

DOPS �  For Clinical Skills

Case Based Discussion �  For Clinical Reasoning

Fieldnotes �  For ‘non-technical’ skills: �  Professionalism �  Collaboration and teamwork �  Communication �  Relating to patients

DOPS �  For Clinical Skills

Case Based Discussion �  For Clinical Reasoning

Fieldnotes �  For ‘non-technical’ skills: �  Professionalism �  Collaboration and teamwork �  Communication �  Relating to patients

�  Challenge of introducing change in a complex, busy clinical environment.

�  Cultural barriers are more challenging than organisational and logistical ones.

�  Focus on where we can add value

�  We just need to make a start! .

CBME World Summit 2016 J Boland et al CAI.

References �  Boland J (2016) “Entrustable Professional Activities: Placing trust at the centre of

education, training and assessment in anaesthesia” CAI Annual Congress, UCD, Dublin, May 2016

�  Brown N, Cooke L. Giving effective feedback to psychiatric trainees. Adv. Psy. Treat. 2009;15(2):123-8.

�  Durnin S (2006) “Evaluation of a Pilot Study of Fieldnotes in Anaesthetic Trainees in Ireland” Thesis submitted in partial fulfilment of the Masters in Clinical Education, National University of Ireland Galway

�  Harrison C, and Val Wass (2016). "The challenge of changing to an assessment for learning culture." Medical Education 50 (7) pp704-706.

�  Medical Council (2014) Your Training Counts Report: Results of the National trainee Experience Survey Dublin: Medical Council

�  Ross S, Poth, CN, Donoff, M, Humphries, P. Steiner I, Schipper S, Janke, F, Nichols D (2011) "Competency-Based Achievement System Using formative feedback to teach and assess family medicine residents’ skills. "Canadian Family Physician 57 (9) e323-e330.

�  Rudolph JW, Simon R, Rivard P, Dufresne,R., and Raemer D. (2007)“Debriefing with Good Judgment: Combining Rigorous Feedback with Genuine Inquiry” Anaesthesiology Clinics, 25 (2) pp 361-376, ISSN 1932-2275

�  Sabah R and Krackov SK (2013) "Twelve tips for giving feedback effectively in the clinical environment." Medical teacher 34(10) pp 787-791.

�  ten Cate O, Chen HC, Hoff RG, Peters H, Bok H & van Der Schaaf M. (2015). “Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99”. Medical Teacher, 1-20. doi: 10.3109/0142159X.2015.1060308

�  Voyer S, and Hatala R. (2015) "Debriefing and feedback: two sides of the same coin?." Simulation in Healthcare 10 (2) pp 67-68.

Fieldnotes: Experience and lessons from the Anaesthesia Training Programme in Ireland

Sheena Durnin, Deirdre Bennett, Rebecca Fanning, Patricija Ecimovic, David Moore, Shelley Ross and Josephine Boland