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Table 2 Work environment influences on transfer of training for internal medical trainees

From: Transfer of training from an internal medicine boot camp to the workplace: enhancing and hindering factors

 

Enhancing transfer

Hindering transfer

Opportunity to perform

Opportunities to transfer communication skills

I think there were just certain phrases and ways of having a conversation that I definitely put into my vocabulary for having these conversations. I definitely found myself using them when I have been having those conversations.’ (Trainee 9)

Opportunities to transfer acute care skills

‘I have had a few asthma attacks I have had to phone intensive care about, so I have been more confident with that and the need to get someone else involved.’ (Trainee 6)

Lack of procedural opportunities

‘I still have not yet been able to do any of those procedures because it has just not come up where I am working just now’ (Trainee 3)

‘Because I’m on medicine for the elderly and…there’s not that much opportunity for chest drains.’ (Trainee 4)

I have done some lumbar punctures, not so much chest drains and ascitic stuff, but that is just because of the jobs I have been on.’ (Trainee 17)

Supervisory/Peer support

Supervisor availability

‘I had the oncology registrar looking over my shoulder being my assistant at the time, but I managed by myself without any input and I was really confident that I was doing the right thing.’ (Trainee 12)

Peer support

‘There is a bit of bouncing ideas off each other when there is nobody more senior about.’ (Trainee 20)

Lack of supervision once deemed competent

I have not received any feedback in the workplace…If you are competent with a procedure…you tend not to be directly supervised in the workplace.’ (Trainee 1)

Supervisor skill decay

‘A lot of good registrars have said that they’re not trained to use them [atraumatic lumbar puncture needles] and then obviously that’s the way we should be doing LPs [lumbar punctures], that’s obviously a bit tricky’ (Trainee 25)

Strategic link

Link to IMT curriculum

‘I wouldn’t really know what the organisational goals are, but I think it’s very clear what the IMT goals are, there’s no uncertainty about what you need to do there, and I think that the course definitely aligned with that’ (Trainee 24)

 

Transfer climate

Feeling empowered to change practice

‘Unfortunately, that [aseptic approach] wasn’t happening in the hospitals but as of now we lead by example.’ (Trainee 10)

‘if you are coming up against that kind of culture, you can say “this is what the evidence says to do, and we practise evidence-based medicine.”’ (Trainee 24)

Mastery learning resources

‘to have access to those materials thereafter because of all the learning packs provided good revision…I can look through them just before I do a procedure just as a point of reference.’ (Trainee 7)

Lack of equipment

‘It can be difficult to find things like sterile gloves on the ward. So that’s the challenge - getting the right equipment.’ (Trainee 4)

‘Even just getting the right gauge needles for lumbar puncture or the right dressing pack, that really simple stuff, certainly the wards I had worked on have really struggled to provide all of that in a consistent way.’ (Trainee 8)

Resistance to change

‘I don’t think a lot of people are very interested in helping you find gowns and stuff to do lumbar punctures.’ (Trainee 2)

‘’Oh, why are you doing that?’, even just with a lumbar puncture I try and find an introducer needle, and they are like ‘you don’t need an introducer needle, that’s not what you need’. I feel like the attitude of people has been like ‘oh, it doesn’t really matter you know.’’ (Trainee 17)

Accountability

ePortfolio

‘I think ePortfolio is a big driver. It is one of the things that helps us to keep track with what we are doing.’ (Trainee 22)

Personal responsibility

Thinking ahead, I guess if you are going to be the registrar on call and you are the one that it is going to be escalated to, you want to be able to be competent and confident in procedures that are quite common, that you might have to do.’ (Trainee 21)

‘I want to be a better doctor…I am keen to do my job well.’ (Trainee 19)

‘You have got to be driven in yourself to do it’ (Trainee 17)

Lack of accountability in the work environment

- Supervisor ambivalence:

‘My supervisor was both fed-up with me and impressed by the fact that I wanted to lay out all my equipment in the order I was using it’ (Trainee 9)

‘I have experienced that, where people who supervise you say “you don’t need a full gown and things like that” or “I don’t do it that way.”’ (Trainee 21)