1. Easing Transition into Working in the NHS:
Piloting an Enhanced Shadowing Programme for Overseas Doctors
J Metcalf#, H Woodun*, N Pierce#, J Golla#, D Basu#, D Cross~,
A Smalldridge~, M Sykes~, M Keaney~, J Illing^
*3rd Year Medical Student, Newcastle University
# North Tees and Hartlepool NHS Foundation Trust
~REACHE North West (Refugee and Asylum Seekers Centre for Healthcare Professionals Education)
^Durham University

2. Aim and Background Aim to facilitate transition to working in the NHS
37% of NHS Doctors qualified overseas1
GMC/DoH commissioned reports identified issues:
Professionalism2,3
Ethics4,5
Communication/cultural differences4,5
Team working4,5
Practicalities4,5
Trust funded pilot programme for overseas junior doctors
The aim of the study was to help transition for overseas drs to work in the nhs. The background is that, many of you will know, 37% of nhs drs are qualified overseas and there has been many studies commissioned by the gmc and DoH, which identified issues around aspects of professionalism, understanding and working within the ethical framework of the nhs, communication, cultural difficulties and team working issues together with practicalities such as financial issues, finding accommodation. This was a trust funded pilot programme for overseas junior drs.
37 % of NHS Doctors are qualified overseas and there have been reports identifying issues concerning professional practice and regulation amongst them. In 2009 GMC commissioned a study to understand how non UK qualified doctors work within the GMC Good Medical Practice regulatory framework5. it was identified that they struggle with areas such as working within unfamiliar ethical and professional frameworks, communication and cultural differences, hierarchies/team working and practical issues eg. accommodation and finances. Even in our trust, about 20% of FY doctors entering Foundation Training at NT&H graduated overseas and are supported through buddying and targeted induction. However, with the Trust focus on quality educational developments, we have developed this enhanced programme of shadowing for overseas trainees, commencing July The study aims to answer questions raised in the literature by implementing recommendations and exploring perceptions of programme participants and clinicians working with them regarding on how it helped or hindered. This is important both locally for this/subsequent cohorts of doctors and for the Trust to develop improved learning and support to enhance emotional wellbeing and improve working practices, thus improving patient care. We may identify transferable findings to inform programmes elsewhere. In 2011 reports from the UK National Patient Safety Agency2 and the UK House of Commons Health Committee3 identified issues concerning professional practice and regulation amongst overseas doctors. In 2009 an ESRC funded project examined the experiences of UK and non UK medical graduates during transition into the UK Foundation training programmes4 and the GMC commissioned a study to understand how non UK qualified doctors work within the GMC Good Medical Practice regulatory framework5.overseas doctors as struggling with areas such as working within unfamiliar ethical and professional frameworks, communication and cultural differences, hierarchies/team working and practical issues eg. accommodation and finances. They made comparable recommendations for easing transition/supporting overseas doctors, including the provision of educational resources before starting work, support in practice including longer shadowing, targeted NHS induction, buddying/mentor schemes and practical support for social issues. Since % of 84 FY doctors entering Foundation Training at NT&H graduated overseas and are supported through buddying and targeted induction. However, due to educational governance issues and review of literature and Trust focus on quality educational developments we are developing an enhanced programme of shadowing for overseas trainees, commencing July The study aims to answer questions raised in the literature by implementing recommendations and exploring perceptions of programme participants and clinicians working with them regarding on how it helped or hindered. This is important both locally for this/subsequent cohorts of doctors and for the Trust to develop improved learning and support to enhance emotional wellbeing and improve working practices, thus improving patient care. We may identify transferable findings to inform programmes elsewhere. Slowther’s GMC commissioned study: explore the experience of non UK qualified doctors working within the GMC Good Medical Practice (GMP) regulatory framework. Illing’s ESRC funded study : transition of UK/overseas graduates into the NHS, to identify factors contributing to success or failure in transition to the UK workplace. views on preparedness to practice, concerns and differences between UK and overseas doctors, including team-working/patient centered practice and communication issues. interpretation of the data based on Hofstede’s work6 on cultural differences/transitions is given to suggest ways to support overseas doctors’ transition to work in the UK.

3. Methods 5 day programme pre FY shadowing July 2013
Informed by literature and discussions with overseas doctors and supervisors within trust
Included NHS and Trust specific sessions
Engaged with REACHE to deliver sessions
The program lasted five days and was held before the foundation shadowing week in July last year. Based on literature and discussions with overseas doctors and supervisors within the trust, we included NHS and Trust specific sessions. We also engaged with REACHE to deliver some sessions. REACHE is a team that includes senior educators and a linguist with experience of working with refugee and overseas Drs. Refugee and Asylum Seekers Centre for Healthcare Professionals Education is a North West organisation, which assist Refugee and asylum seeking Healthcare Professionals (RHPs) to register their qualifications in the UK, partly by co-ordinating their integration and delivering advice training and support to refugee healthcare professionals on an individual and a group basis and providing a friendly mutually supportive drop-in.

4. Week before Foundation Shadowing July 2013
And this is the timetable. You can see, we covered a wide range of issues starting with some orientation to the hospital with a treasure hunt around the hospital. Then we attended fy1 dr teaching session. We did some orientation around the nhs and patient journeys and we moved into the communication skills, summarising, clinical governance sessions, cultural diversity that REACHE delivered. We also had a trust specific cultural diversity where we got people in to speak to the trainees about different groups in our area, for example Jehovah's Witness. And the final day was a ward based simulation that we run for our final year students. And then, a tour of the local area and Personal development plans. And on the evenings, there were some social events which you can see there.

5. Methods: Evaluation Ethical approval not required (by NRES)
Anonymised pre and post Likert scale questionnaires including
Knowledge of the structure of NHS
Awareness of communication issues/cultural diversity
Patient centred approach/team working
Ethical framework eg consent and confidentiality
Analysed using paired T-tests
Semi structured individual interviews and participant observation
Participants’ expectations
FAQs during sessions
Concerns/suggestions
Evaluation questionnaires for each session looking for themes
The methods of evaluation: we checked nres and we did not require ethical approval for this. We used anonymised pre and post likert scale questionnaires, analysed with paired t-test, covering various areas about knowledge, and issues about communication skills, patient centredness, ethics. We also did semi structured individual interviews and the participant, myself, observed also what went on, identifying participants’ expectations, FAQs during sessions and participants’ concerns. And we also did evaluation questionnaires for each session just to look for themes.

6. Results 7 participants Response rates
3 foundation doctors
2 international medical students
1 refugee doctor
1 clinical attaché
Response rates
Pre and post Questionnaires: 100%
Session Evaluations: 93.8%
Overall programme rated ‘very good’ (highest rating) by 100% of respondents
In terms of results, there were 7 participants, a wide spread, it wasn’t the initial target audience : 3 Foundation Doctors, 2 international medical students including myself, 1 refugee doctor, 1 clinical attaché. The Response Rates for the Pre and post Questionnaires was 100% and for the Session Evaluations was 93.8%. The reason of the 93.8% is because we looked at the response of all of the different questionnaires for the 5 days. In those evaluations, the programme was given the highest rating of “very good” by all respondents.

7. Significant results *P=0.042 *P=0.011
Just to show you the pre and post questionnaire significant changes, which showed improvements to a more positive response. The 3 statements are: I understand the structure and hierarchy of the NHS, Most doctors in the UK reflect on their practice and keep themselves up-to-date and I am confident about managing an acute situation in the hospital.

8. Verbal feedback
Verbal feedback included Improved communication skills, Improved team working skills, Ethical awareness, Understanding of Governance.

9. Changes to practice And self-identified changes to practice were
Patient centredness
Communication skills
Professionalism
Seeking help

10. Comments/Improvements
Comments about the programme and suggested improvements included: (Give example of colloquialism)
unexplained abbreviations
confusing diagrams
abstract notions
wordy slides
a lot of information in a short time
more similar sessions
more practice opportunities
explaining abbreviations
colloquial language
UK medical curriculum
career options

11. Discussion: Strengths and Limitations
Valued by participants and Trust
Targeted, flexible and responsive training
REACHE highly skilled
Full evaluation underway
Limitations:
Small numbers/mixed group
Observer bias as evaluation by participant
Stigma
Time to release trainees
Measuring outcomes difficult as looking at whole career
Thinking about the strengths and the limitations of the study. There were a number of strengths, for instance, it was valued by the ppts and the Trust. Senior clinicians felt there were improvements. It was targeted, flexible and responded to the needs of the ppts because of the small number of trainees. The reache team is higly skilled in this area and they were hugely appreciated by everybody and we have got a full evaluation of the programme on the way.
Limitations are that it was a small group, it wasn’t our target group. I was a ppt myself, so there may well be observer bias. There was some stigma about ppts being in it and why they have been asked to go. Releasing trainees is difficult and the follow up to measure significant changes in outcomes will be difficult, for example, to follow up if any trainee received a complaint relating to his/her communication skills in his/her career.

12. Discussion Programme addressed issues identified by studies
Responsiveness to individuals was crucial
Participants identify on-going benefits:
One participant passed PLAB and now employed by Trust
Key identified improvements:
Patient centredness
Communication skills
Professionalism
Seeking help
Future programmes influenced by feedback
How to generalise locally, regionally, nationally?
We felt that the program did address the issues identified by the other studies. Being able to respond to the ppt’s needs was important. Participants identify ongoing benefits. For example, one participant passed PLAB and now employed in Trust. Key identified improvements are Patient centredness, Communication skills, Professionalism, Seeking help. Future programmes has been and will be informed by feedback. One of the issues is how do we generalize this, locally, regionally and potentially nationally as well. I understand there has been thoughts about merging regionally.

13. Future plans Trust funded PhD student undertaking realistic evaluation
Follow up on 2nd/3rd July 2014 informed by feedback
More role plays for communication skills
Clinical simulation including human factors
2nd programme May 2014 (2 days only) for juniors in Trust including clinical attachés and refugee docs
3rd programme (full week) Autumn 2014 for new cohort
So the future of this programme now is, that we have appointed a trust funded phd student to do a realistic evaluation of the whole programme. We’ve already had a follow up for the first cohort which had more role plays and simulation, responding to the feedback that was given. There has been a 2nd programme for those who have been working in the Trust but could not get on the 1st programme. We also got plans in place to run another programme this autumn for a full week for incoming doctors.

14. Conclusion Targeted programme to overseas doctors
Perceived Benefits for participants and Trust
Addressed issues around
NHS cultural values
Professionalism
Patient Safety
Ethics and communication skills
Practicalities
Now embedded (and funded) within Trust
So in conclusion, this target programme for overseas drs had perceived benefits for the ppts and the trust. It addressed issues around NHS cultural values, Professionalism, Patient Safety, Ethics and communication skills, Practicalities. The trust has been been so impressed with it that there are already plans for it to be an ongoing trust funded programme.

15. References 1.
2. NCAS 2011: UK National Patient Safety Agency. National Clinical Assessment Service: Concerns about professional practice and associations with age, gender, place of qualification and ethnicity /10 data (February 2011).
3. UK House of Commons Health Committee. Fourth report. Revalidation of Doctors. London: House of Commons,
4. Illing, J et al. The experiences of UK,EU and non-EU medical graduates making the transition to the UK workplace: Full Research Report, ESRC End of Award Report. RES Swindon: ESRC 2009
5. Slowther A, Lewando Hundt GA, Purkis J, Taylor R. Experiences of non-K-qualified doctors working within the UK regulatory framework: a qualitative study. J R Soc Med 2012; 105:
Thank you very much.