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G214 USING CHILDREN’S VIEWS TO IMPROVE PRACTICE: WHAT THEY SAY ABOUT INJECTIONS

L. C. Haines, P. Kirby, K. Read, M. Lynch, E. Estlin.The Royal College of Paediatrics and Child Health, London, UK

Aims: The study was undertaken to establish whether children of varying ages and illness experience can be supported using appropriate techniques to express their views about a common medical procedure to inform clinical practice.

Method: Focus group discussions (incorporating a draw/write technique for the 3–9 year olds) were undertaken about children’s experiences and perceptions of injections and how they could be improved. Older children (11–17) also discussed what they would teach doctors about giving injections. Consultations with healthy school children were facilitated by teachers; consultations with children with a disability by an experienced researcher and those with children with acute and chronic illness by trained young researchers (16 years).

Results: 74 children were consulted (36 boys 38 girls 3–17 years). Strategies which could improve the experience for children included parental presence, age appropriate distractions, rewards, being properly informed, and personal coping strategies. Children appreciated technically competent, friendly medical staff who told them the truth, invited feedback, and provided pain relief.

Conclusion: Children of all ages including those with a disability were able to understand the question, talk about their experiences and articulate what makes injections easier. Medical staff clearly have a role in improving the experience but children recognise their own ability to help, which should be encouraged. The consultation demonstrated that children of all ages can offer a valuable perspective on medical procedures and wish to be seen as active participants. The children also made it clear that they wanted to be involved in teaching doctors how to communicate with children. The results will be used to inform medical guidance and public information posters.

G215 DEVELOPING A CORE CURRICULUM FOR THE PAEDIATRIC COMPONENT OF VOCATIONAL TRAINING FOR GENERAL PRACTICE BY THE DELPHI TECHNIQUE

AShrivastava.Southend Hospital, Essex, UK

Background: Paediatrics is a popular choice among trainee senior house officers (SHOs) from Vocational Training for General Practice (GPVTS). A local curriculum would ensure that all doctors entering general practice have the necessary competencies and would also be the basis for the educational approval of SHO GPVTS posts during joint RCGP/RCPCH college visits.

Aims: To establish a local core curriculum for the paediatric SHOs from GPVTS.

Methods: A two round Delphi technique was employed in the curriculum planning to generate a consensus among a panel of experts comprising 16 GPs, six consultant paediatricians, and three specialist paediatric registrars. Generic skills (Good Medical Practice, GMC) and training objectives of GPs as described in the Joint statement (RCGP/RCPCH, 1997) was the basis of the starter questionnaire (round one) containing learning outcomes for the core curriculum. Round two questionnaires were sent subsequently with the participants asked to rank each learning outcome. Data were analysed using Microsoft EXCEL 2003. Priority classification (agreement among participants of >80% (priority 1), 50–79% (priority 2), and <50% (priority 3)) ascertained the strength of these rankings for each learning outcome.

Results: All 25 questionnaires were returned in both round one and two (100% participation). Twenty one participants in round one felt that five learning outcomes were inappropriate (newborn and advanced paediatric resuscitation, venepuncture, management of fractures, genetics) and seven “new” learning outcomes were suggested. These changes were made in round two questionnaire. Finally, eight learning outcomes (autism, hearing screen, allergy, arthritis, cystic fibrosis, malignancy, nutrition, and special schools) were designated priority 3, four learning outcomes (ADHD, enuresis, cerebral palsy, and hearing) priority 2, and 30 learning outcomes as priority 1.

Conclusions: The Delphi process helped in establishing the 30 important learning outcomes for the core curriculum for the paediatric SHOs from GPVTS. Consensus approach should help in easy implementation of the curriculum. Shorter period of training in future may not achieve all learning outcomes.

G216 CAN SIMULATION RECREATE A REALISTIC AND APPROPRIATELY STRESSFUL ENVIRONMENT TO OBSERVE TEAM BEHAVIOURS IN THE SETTING OF PAEDIATRIC CRITICAL ILLNESS?

N. Gosling1, M. Moore1, C. Williams2, M. Festa2.1Advanced Patient Simulator, St George’s Hospital, London, UK; 2South Thames Retrieval Service for Children, Guy’s Hospital, London, UK

Introduction: Effective teamwork is essential to flight safety. Behavioural markers have been identified and shown to characterise a cockpit crew’s response to critical incidents.1 Similar markers and team interactions have been used to analyse teamwork in emergency medicine and have been incorporated in team training with improvement in team behaviours and a reduced error rate.2 High fidelity simulators provide an opportunity to recreate realistically stressful environments in which to observe and teach team behaviours.

Aim: To create a realistic environment using a high fidelity simulator to mimic a critically ill child, in order to allow identification of adaptive team behaviours in course participants.

Methods: Collaboration between the regional retrieval service and the advanced patient simulator laboratory led to the development of a high fidelity simulated five part case scenario involving a critically ill child presenting to a local hospital and requiring stabilisation and transfer to a tertiary paediatric intensive care unit. Candidates acted their own role and were observed in the simulator so that established team behaviours could be identified and digitally recorded for feedback. Post-course questionnaires were used as a subjective evaluation of candidate experience after each of the first three courses (n = 25).

Results: Candidates evaluated the simulator as realistic and identified communication and teamwork as key themes. Adaptive team behaviours were observed. These included examples of team communication, leadership, assertiveness, situation awareness, problem anticipation, and problem solving.

Conclusion: High fidelity paediatric simulation can be used to recreate an appropriately stressful and realistic environment to allow identification and feedback of adaptive team behaviours in the setting of a critically ill child, and may be useful in improving teamwork and reducing error rates in clinical practice.

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G217 MEDICAL SIMULATION TRAINING FOR ACUTE PAEDIATRIC TEAMS: THE INTRODUCTION OF A NEW COURSE AND CONCEPT TO TRAIN ATTITUDES AND BEHAVIOURS FOR THE WORKPLACE

R. P. Bowker1, S. A. Smith2.1Department of Academic Child Health, Queen’s Medical Centre, University of Nottingham, Nottingham, UK; 2Department of Child Health, Queen’s Medical Centre, Nottingham, UK

Background: Training requires the acquisition of knowledge, skills, attitudes, and behaviours. There is little emphasis in training on the attitudes and behaviours, in part because role models for trainees cannot be easily engineered. However, the attitudes and behaviours of staff contribute significantly to medical errors and incidents. Computer driven manikins have been used in training anaesthetists in the UK for several years. A paediatric manikin has been developed and is available for training simulated scenarios. Simulation of life like clinical scenarios can be used to assess competences in various fields and explore the human behaviours and attitudes required for managing an acute situation.

Method: A new course targeted at teams from paediatrics and emergency medicine (including doctors and nursing staff) was developed at the Trent Simulation and Skills Centre, Nottingham, in conjunction with the Bristol Medical Simulation Centre. The learning objectives of improving recognition and use of good communication skills, leadership skills, team working, and decision making techniques were delivered using a series of workshops, scenarios, and structured video feedback (some of which will be demonstrated during the presentation). A structured questionnaire was distributed to the candidates at the end of the course and after 6 weeks to help determine if any longer term changes in behaviours had been established back in the workplace.

Results: From analysis of the questionnaires, 85% of candidates on the course achieved their personal learning objectives. At 6 weeks after the course, over 85% of the candidates could still recognise changes in their attitudes and behaviours related to the feedback from the course.

Discussion: Changing attitudes and behaviours is difficult to achieve and even harder to assess. A short course will not be successful in isolation. However, repeated exposure to team training with structured feedback and follow up in the work place will contribute to this important yet neglected area. The delivery of interdisciplinary training in teams is a new concept for paediatric simulation training, but we hope to develop it further in the future. The long term challenge will be to develop a tool for assessing professional attitudes and behaviours.

G218 ROLE OF THE INTERVIEW IN THE PAEDIATRIC SENIOR HOUSE OFFICER SELECTION PROCESS

D. Jyothish, V. Diwakar, H. Goodyear.Birmingham Children’s Hospital NHS Trust, Birmingham, UK

Aim: To evaluate the usefulness of the paediatric senior house officer (SHO) selection interview; to determine the inter-interviewer reliability; and to examine the factors affecting the interview process.

Methods: Data were collected from a regional paediatric SHO selection interview. Applicants were invited for the interview following a standardised short listing process. 123 candidates were interviewed by an interview board constituted by three panels each having two members. The same three predetermined questions that explored clinical knowledge, communication skills, and insight were asked to each candidate. Inter-interviewer reliability was calculated using Spearman’s Rho and Pearson’s r tests of concordance. Friedman’s test was used to determine statistical differences between the scores for the three questions. Analysis of variance to determine shifts in scores based on gender and time of interview was done using the Kruskal-Wallis test.

Results: Inter-interviewer reliability within each panel was 65%. Female candidates performed better than males. Candidates who were interviewed in the morning session had better scores than those in the afternoon.

Conclusions: This study showed that there is reasonable concordance (65%) in scoring between interviewers in spite of there being differences in their gender and previous interviewing experience. The study also confirms the results of previous studies that females perform better than males in medical selection interviews. The differences between morning and afternoon sessions might be attributed to bias in allocation of times based on travelling distances. We suggest that inter-interviewer reliability can be further enhanced by more formal interviewer training.

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G219 AN 8 YEAR REVIEW OF THE OUTCOME OF APPOINTMENTS TO THE EASTERN DEANERY PAEDIATRIC SPECIALIST REGISTRAR TRAINING PROGRAMME

A. W. R. Kelsall, D. M. Williams, C. L. Acerini, D. C. Mabin.1Addenbrookes NHS Trust, Cambridge, UK

Aims: To review the outcome of appointments to the Eastern Region Paediatric Specialist Registrar (SpR) Training Programme since September 1996.

Methods: SpRs were identified from programme directors’ and deanery databases. All trainees appointed between 1996 and 2004 to numbered SpR, fixed term (FTTA), and locum training (LAT) training posts within the deanery were included. Trainees with planned rotations to neighbouring deaneries were excluded.

Results: Since 1996 there has been an almost threefold expansion of the programme, which aims to provide core training in district general hospitals with the opportunity to spend 3 years in teaching hospitals. There have been 184 SpR appointments, 89 (48%) male and 95 (52%) female. The number of hospitals offering posts has increased and their distribution changed. In 1996 there were 30 posts in 10 hospitals: 21 posts in nine district general hospitals and nine posts in one teaching hospital. Currently there are 79 posts in 17 hospitals: 44 posts in 15 district general hospitals and 35 posts in two teaching hospitals. There were 30 LAT/FTTA appointments of whom 22 (73%) have successfully obtained Type 1 numbers. Part time training was arranged for 40 (22%) trainees including two males. There have been 17 (9%) interdeanery transfers for training reasons: five (3%) SpRs entering and 12 (6%) leaving the deanery. Out of programme experience (OOPE) was granted to 13 (7%) SpRs for clinical attachments and 18 (10%) for research work. There have been six (3%) appointments to National Grid programmes since 2001. Despite the large numbers of trainees only 10 (6%) SpRs have had difficulties, six with health issues and in five there were clinical concerns. Only three trainees have received a RITA-E and two of these successfully completed their training. Seven (4%) trainees have dropped out of the programme: two because of their health and five for personal reasons (four changing careers and one returning home). Fifty five SpRs have completed their training and gained their CCST. Of these, 46 (84%) are working as paediatric consultants in the UK: 22 (40%) in general paediatrics; nine (16%) as community paediatricians; and 15 (27%) in specialist posts, allergy (1); endocrinology (3); intensive care (4), neurology (2); neonatology (4), oncology (1). Only four appointments have been to university/academic positions. With at least 13 (24%) consultants appointed choosing to work part time and nine (16%) of post-CCST trainees working overseas, only 33 (60%) SpRs have accepted full time consultant posts in the UK.

Conclusions: There has been a significant expansion in SpR training posts in both district general hospitals and teaching hospitals. Only a small proportion of SpRs have had difficulties related either to health or clinical competency. While many trainees who obtain a CCST work as consultants in the UK, paediatric work force planning continues to be a challenge with so many SpRs choosing to work part time or overseas at the completion of their training.

G220 SAFER PRESCRIBING: DOES EXPERIENCE MATTER?

L. Menon, Z. Taylor, D. Tuthill.Llandough Hospital, Cardiff, UK

Introduction: Infants and children are especially vulnerable to medication errors due to their physiological immaturity and small size. These form the second largest awards in paediatric litigation cases. It is commonly assumed that experience and qualification are beneficial for safer prescribing.

Aim: To evaluate the prescribing ability of paediatric senior house officers (SHOs).

Methods: A standardised evaluation of SHO prescribing ability was conducted at the conclusion of a 1 hour interactive session at the induction programme. This consisted of four basic questions on prescribing common medications, focussing on issues particular to paediatrics, for example postnatal age and weight. Calculators, medicines for children (RCPCH/NPPG publication), and surface area charts were provided. Additional information on postgraduate qualifications and paediatric experience was recorded.

Results: Thirty two SHOs were evaluated. Around a third (10/32) answered all four questions correctly, of these 6/10 had no experience in paediatrics. The other 22 doctors answered at least one question or more incorrectly. χ2 analysis was performed to explore the effect of experience and qualification on scoring.

Conclusion: In optimal conditions, a substantial proportion of trainees make unforced errors in prescribing drugs for children. Previous paediatric experience or postgraduate qualification does not infer competence to prescribe.

G221 PERCEPTION OF EDUCATIONAL CLIMATE BY TRAINEE PAEDIATRICIANS: A REGIONAL STUDY

A. M. Skinner, S. McAleer.Gloucester Royal Hospital, Gloucester, UK

Aim: The aim of this study was to assess the educational climate of senior house officers (SHOs) and specialist registrars (SpRs), to identify both positive and negative perceptions of their education and training.

Methods: The target population included 81 SpRs and 186 SHOs working in 17 paediatric departments in the West Midlands Deanery. The educational climate was assessed using a validated inventory consisting of 40 items divided into three subscales: perception of role autonomy (14 items), of teaching (15 items), and of social support (11 items). On a 5 point Likert scale of 0–4, a score of 3 was taken to indicate satisfaction. The SPSS package (version 11.0) was used to determine the mean score and standard deviation (SD) for the total population and for each item. Differences in the mean scores of SpRs and SHOs were explored as well as the influence of gender.

Results: The study population included 58 SpRs and 75 SHOs, giving a response rate of 69% and 40%, respectively. The mean global score was 105.5/160 (SD 18.6). Only 12 items scored at or above 3, six pertaining to perception of teaching and three to each of the subscales of role autonomy and social support. The subscale for teaching was most highly rated, mean score 42.6/60 (5.7) followed by role autonomy 36.8/56 (6.0), and social support 28.5/44 (5.2). SHOs and SpRs rated seven items differently (p<0.05), four relating to role autonomy and two each to social support and teaching. SHOs scored all items more highly except that of current training and preparation for the next grade. There were seven items with significantly different mean score (p<0.05) between males and females, males scoring more highly for six items. Five items dealt with perception of social support and referred to on call accommodation, physical safety in the work environment, access to career advice, availability of counselling services, and the presence of a no blame culture.

Conclusions: Measures could be taken to improve satisfaction in all areas but especially that of social support, which is particularly relevant to female trainees. SHOs were more satisfied than SpRs with several aspects of role autonomy. However, SpRs felt more prepared to proceed to the next grade. Evaluation of the educational climate can have a formative role, identifying problems and monitoring the effect of change.

G222 BARRIERS TO EDUCATIONAL PROGRESS OF OVERSEAS DOCTORS IN PAEDIATRICS: A QUALITATIVE STUDY

J. Mahajan.Sheffield University, Sheffield, UK; 2Rotherham District General Hospital, Rotherham, UK

Recent articles in the BMJ Career Focus (2004) highlight many problems faced by overseas doctors who want to train in the UK. Despite many anecdotal accounts there is paucity of objective research in this area.

Aims: To explore the factors that can influence the progress of doctors from Indian subcontinent who are in the early years of training in paediatrics.

Methods: Overseas doctors training in paediatrics in North Trent Deanery participated in the study. Focus groups were used to collect data; two focus groups, each with 4–5 participants, were conducted at 6 weeks intervals. Semi-structured, one-to-one interviews were conducted to add more understanding and depth to issues highlighted in focus groups. The focus groups and interviews were tape recorded; the tapes were transcripted and data were anlysed using grounded theory; open codes were formed and concepts identified using microanalysis, and initial theories were built. The data were verified by triangulation.

Results: Some common themes that emerged were: communication (not necessarily language) difficulties: lack of understanding of team working; cultural differences and isolation both at work and outside. Lack of information about the NHS in country of origin, VISA regulations, difficulty in finding jobs were also identified as barriers. RCPCH exams were considered fair but different disease profile and emphasis, and lack of exam oriented teaching made them harder. Access to better information support systems before coming to UK, early mentorship on arrival, awareness of the issues among the members of team, and workshops on communication skills specifically directed at overseas doctors were identified as the means to overcome these barriers.

Conclusions: Barriers in education of the overseas doctors originate from communication difficulties, a lack of awareness about the systems of education and work culture in the UK, and a similar lack of awareness among the healthcare professionals within the UK of the specific issues related to overseas doctors. Increased awareness on both sides will be required for successful strategies to overcome these barriers.

G223 TEACHING AND ASSESSMENT OF EQUIPMENT COMPETENCIES ON THE NEONATAL INTENSIVE CARE UNIT: USE OF THE TRANSPORT INCUBATOR

L. Lee, C. Mayes, A. Jain, P. Cairns.Neonatal Intensive Care Unit, St Michael’s Hospital, Bristol, UK

Questions: Is training during induction for junior medical staff sufficient to ensure competency in the use of the transport incubator? How do we assess this competency?

Assessment and Outcome: We identified seven areas of competency that are required to use the transport incubator (see table). We designed a structured questionnaire based assessment that required practical demonstration within each area of competency. The first assessment was carried out on five senior house officers (SHOs) and four specialist registrars (SpRs) who had been in post for 5 and 4 months, respectively. The SHOs had received a 15 minute overview of the transport incubator without hands on training. The SpRs received no formal training. Their performance was assessed as suboptimal (see table). Following the first assessment, the induction was restructured to formally address each of the previously identified competencies. Six new SHOs and 1/5 new SpRs received this modified induction in the first week of the post. The second assessment was carried out 6 weeks after this induction.

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Abstract G224 Overall group mean score (highest and lowest items shown)

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Discussion: Medical staff need to operate equipment safely and this might be assessed by a competency based process. We focussed on the transport incubator because staff use this equipment frequently and early in their posts, and we highlighted the potential for poor competency in new staff. After introduction of structured competency training, our assessment at 6 weeks was similar to that achieved previously after 5 months. This suggests an improvement in skills acquisition. However, this improvement is still inadequate and we plan to follow induction with self assessment. In the light of the above it is important to plan for the appropriate support of staff in the early days of a post until their level of competency is satisfactory. We intend to compare the competency of the current group of staff at 5 months with those achieved in the first assessment. It is possible that this level of competency might extend to other pieces of equipment and we are now devising medical equipment competencies for all commonly used pieces of equipment on neonatal intensive care units.

G224 COMMUNICATION SKILLS IN PAEDIATRICS: A STRUCTURED RATING SCALE TO ASSESS THE EDUCATIONAL NEEDS OF UNDERGRADUATES

M. Y. James-Ellison.Swansea Clinical School, Swansea, UK

Introduction: Communication skills can be enhanced with training. The first step towards developing a training programme is assessing students’ needs by measuring their present abilities.

Aims: To develop a tool to measure students’ communication skills during real paediatric patient interactions and to determine areas of strength and weakness.

Methods: A structured 5 point rating scale comprised of 20 items based on the Calgary–Cambridge Guide was devised, piloted, revised, and then used by tutors to rate student’s communication skills (item score ⩽2 unacceptable, 3 mixed, ⩽4 acceptable; α coefficient, 0.92). Teachers rated all fourth year students (of UWCM) in several hospitals during one clinical attachment, by observation during clinical interviews.

Results: Twenty eight scales of 39 returned (response rate 72%); 28.5% were incomplete with non-rated (student not observed) items and no student scored ⩽2. Individual student scores: 21.4% (6/28) were acceptable (score ⩾80). Most (75%) had “mixed” scores (60–79), none unacceptable skills (score ⩽40). Highest scores were building relationships and initiating communication. Lowest scores were gathering information (7.1% acceptable) and explaining and planning (3.6% acceptable). Male v female scores showed no difference (t test, p>0.2).

Conclusion: Results are based on good response rate but small student numbers and consultations and several teachers (with no scale training) and some missing data. The scale was easy and acceptable to students and teachers. There seems a true need to improve students’ skills—building on intrinsic abilities. Deficiencies in gathering information and explaining and planning were identified (which agree with the findings of contemporaneous focus group studies (unpublished)). We suggest the scale is suitable for formatively assessing students’ communication skills within the clinical environment; and further validation repeating the needs assessment (more students/guidance to teachers) and use results to plan training and feedback.

G225 INTERPROFESSIONAL COMMUNICATION: INVESTIGATING COMMUNICATION PROCESSES BETWEEN PAEDIATRIC DOCTORS AND OTHER HEALTHCARE PROFESSIONALS

A. W. Rizvi1, F. D. Merali1, R. Moran1, N. Furness1, R. Davis1, S. Mirrahimi1, J. I. Baeza1, S. N. Faust2.1Tanaka Business School, Imperial College, London, UK; 2Department of Paediatrics, Imperial College St. Marys Campus, London, UK

Background and Aims: The literature indicates that ineffective communication is directly detrimental to patient care. The recent EU directed change to shift work for junior doctors has made efficient communication more of a challenge. This study aimed to determine how patient care, junior doctors’ training, and team morale was affected by specific communication processes.

Method: A multi-method qualitative case study. Non-participant observation was used at all the medical handovers and ward rounds over a 1 week period (PICU: 14 handovers, 14 ward rounds; wards: 21 handovers, 14 ward rounds; and 3 nursing handovers). Twenty face to face, semi-structured interviews were carried out with hospital paediatricians of different grades and a range of other healthcare professionals.

Results: Communication in the department was linked with: (a) systems in place (shift work, handover, documentation); (b) structures existing between units of the department and doctors and other healthcare professionals; (c) inherent culture with regard to hierarchy and leadership. Communication was not optimal. The data showed that staff were dissatisfied with training and there was an overall feeling of low morale, which could potentially be detrimental to patient care.

Conclusions: Although this was a small scale case study it is reasonable to suggest that these findings may occur in other paediatric units struggling to balance new patterns of work. Handover should be multidisciplinary to ensure completeness and reduce error; creating more opportunities for interaction between doctors of different grades and other healthcare professionals will benefit training and boost morale, contributing to an improvement in patient care. Although work patterns have changed, work practices have been slow to adapt which is preventing this department reaching its full potential.

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G226 JUNIOR PAEDIATRIC STAFF’S KNOWLEDGE OF CHILD PROTECTION POWER AND COMMON LEGAL SITUATIONS

C. S. Ashtekar, M. Alfaham, E. stallard, D. Tuthill.1Llandough Hospital, Cardiff, UK

Background: Awareness of common medicolegal principles is important in the current atmosphere of increasing litigations, legislations, and government reports—for example, Kennedy.

Aim: To determine paediatric junior medical staff’s knowledge of child protection powers and common basic legal situations.

Methods: A standardised structured interviews was developed exploring common issues with important legal implications for paediatric practice. It focused on areas such as child protection powers, Children’s Act, responsibility/accountability, Bolam principle for good medical practice and Gillick competence. We attempted to contact all 180 paediatric junior medical staff in Wales by telephone.

Results: Interviews were conducted with 119/180 (66%) doctors; 46/56 SpRs (82%), and 73/124 SHOs (59%).

Conclusion: Few junior staff have adequate knowledge of the basic legal principles and practice as they relate to children. Worrying deficiencies surrounding the understanding of child protection powers are widespread.

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