Exodus? The training paths and plans of postgraduate medical trainees, under the Royal College of Physicians of Ireland

Background: In 2006, the Buttimer report highlighted the paucity of demographic data on those applying for and entering postgraduate medical education and training (PGMET) in Ireland. Today, concerns that there is an "exodus" of graduates of Irish medical schools are at the forefront of national discussion, however, published data on PGMET remains inadequate.

Aims: The objectives of this study were to collate existing data relating to trainees and training programmes at three stages of training and to examine the career plans of junior trainees.

Methods: Data from application forms for training programmes, commencing July 2012, under the Royal College of Physicians of Ireland (n = 870), were integrated with data from other existing sources. Candidates entering basic specialist training were surveyed with regard to career plans. Descriptive and comparative analysis was performed in SPSS version 18.

Results: Graduates of Irish medical schools made up over 70 % of appointees. Over 80 % of BST trainees aspired to work as consultants in Ireland, but 92.5 % planned to spend time working abroad (response rate 77 %). Decisions to leave the Irish system were linked to lifestyle, but also to failure to be appointed to higher specialist training. Significant numbers of trainees return to Ireland after a period abroad.

Conclusions: The trainee "exodus" is more complex than is often portrayed. The desire to spend time working outside Ireland must be accounted for in workforce planning and configuration of training programmes. Expansion of HST is a potential solution to reduce the numbers of graduates leaving Ireland post-BST.

A realistic evaluation of track and trigger systems and acute care training for early recognition and treatment of deteriorating ward-based patients: research protocol.

Aim The aim of the study is to evaluate factors that enable or constrain the implementation and service delivery of early warnings systems or acute care training in practice. Background To date there is limited evidence to support the effectiveness of acute care initiatives (early warning systems, acute care training, outreach) in reducing the number of adverse events (cardiac arrest, death, unanticipated Intensive Care admission) through increased recognition and management of deteriorating ward based patients in hospital [1-3]. The reasons posited are that previous research primarily focused on measuring patient outcomes following the implementation of an intervention or programme without considering the social factors (the organisation, the people, external influences) which may have affected the process of implementation and hence measured end-points. Further research which considers the social processes is required in order to understand why a programme works, or does not work, in particular circumstances [4]. Method The design is a multiple case study approach of four general wards in two acute hospitals where Early Warning Systems (EWS) and Acute Life-threatening Events Recognition and Treatment (ALERT) course have been implemented. Various methods are being used to collect data about individual capacities, interpersonal relationships and institutional balance and infrastructures in order to understand the intended and unintended process outcomes of implementing EWS and ALERT in practice. This information will be gathered from individual and focus group interviews with key participants (ALERT facilitators, nursing and medical ALERT instructors, ward managers, doctors, ward nurses and health care assistants from each hospital); non-participant observation of ward organisation and structure; audit of patients' EWS charts and audit of the medical notes of patients who deteriorated during the study period to ascertain whether ALERT principles were followed. Discussion & progress to date This study commenced in January 2007. Ethical approval has been granted and data collection is ongoing with interviews being conducted with key stakeholders. The findings from this study will provide evidence for policy-makers to make informed decisions regarding the direction for strategic and service planning of acute care services to improve the level of care provided to acutely ill patients in hospital. References 1. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidain A et al. Investigating the effectiveness of Critical Care Outreach Services: A systematic review. Intensive Care Medicine 2006; 32: 1713-1721 2. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems for the prevention of Intensive Care admission and death of critically ill patients on general hospital wards. Cochrane Database of Systematic Reviews 2007, Issue 3. www.thecochranelibrary.com 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ (2007) Rapid Response Systems: A systematic review. Critical Care Medicine 2007; 35 (5): 1238-43 4. Pawson R and Tilley N. Realistic Evaluation. London; Sage: 1997

A realistic evaluation of Early Warning Systems and acute care training in Northern Ireland: findings and recommendations

Statement of purpose The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide an impetus for change. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. Results The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. Conclusion These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. References: 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast

The Development of TASTER, a Cognitive Training Game Using Human-Centered Design, Tailored for Children with Global and Specific Cognitive Impairments

Children with Prader-Willi syndrome often exhibit challenging behavior in response to changes to routine. This phenomenon has been linked to a deficit in task switching ability which has been observed in children with the syndrome. TASTER is a cognitive training game which is being designed with input from a group of children with Prader- Willi syndrome, which aims to train task switching ability and thus reduce associated challenging behavior.

Agility and search and rescue training differently affects pet dogs' behaviour in socio-cognitive tasks

Both genetic factors and life experiences appear to be important in shaping dogs' responses in a test situation. One potentially highly relevant life experience may be the dog's training history, however few studies have investigated this aspect so far. This paper briefly reviews studies focusing on the effects of training on dogs' performance in cognitive tasks, and presents new, preliminary evidence on trained and untrained pet dogs' performance in an 'unsolvable task'. Thirty-nine adult dogs: 13 trained for search and rescue activities (S&R group), 13 for agility competition (Agility group) and 13 untrained pets (Pet group) were tested. Three 'solvable' trials in which dogs could obtain the food by manipulating a plastic container were followed by an 'unsolvable' trial in which obtaining the food became impossible. The dogs' behaviours towards the apparatus and the people present (owner and researcher) were analysed. Both in the first 'solvable' and in the 'unsolvable' trial the groups were comparable on actions towards the apparatus, however differences emerged in their human-directed gazing behaviour. In fact, results in the 'solvable' trial, showed fewer S&R dogs looking back at a person compared to agility dogs, and the latter alternating their gaze between person and apparatus more frequently than pet dogs. In the unsolvable trial no difference between groups emerged in the latency to look at the person however agility dogs looked longer at the owner than both pet and S&R dogs; whereas S&R dogs exhibited significantly more barking (always occurring concurrently to looking at the person or the apparatus) than both other groups. Furthermore, S&R dogs alternated their gaze between person and apparatus more than untrained pet dogs, with agility dogs falling in between these two groups. Thus overall, it seems that the dogs' human-directed communicative behaviours are significantly influenced by their individual training experiences. © 2009 Elsevier B.V. All rights reserved.

Factors influencing the output of rural cataract surgical facilities in China: the SHARP study

Purpose: To identify factors associated prospectively with increased cataract surgical rate (CSR) in rural Chinese hospitals.

Methods: Annual cataract surgical output was obtained at baseline and 24 months later from operating room records at 42 rural, county-level hospitals. Total local CSR (cases/million population/y), and proportion of CSR from hospital and local competitors were calculated from government records. Hospital administrators completed questionnaires providing demographic and professional information, and annual clinic and outreach screening volume. Independent cataract surgeons provided clinical information and videotapes of cases for grading by two masked experts using the Ophthalmology Surgical Competency Assessment Rubric (OSCAR). Uncorrected vision was recorded for 10 consecutive cataract cases at each facility, and 10 randomly-identified patients completed hospital satisfaction questionnaires. Total value of international nongovernmental development organization (INGDO) investment in the previous three years and demographic information on hospital catchment areas were obtained. Main outcome was 2-year percentage change in hospital CSR.

Results: Among the 42 hospitals (median catchment population 530,000, median hospital CSR 643), 78.6% (33/42) were receiving INGDO support. Median change in hospital CSR (interquartile range) was 33.3% (-6.25%, 72.3%). Predictors of greater increase in CSR included higher INGDO investment (P = 0.02, simple model), reducing patient dissatisfaction (P = 0.03, simple model), and more outreach patient screening (P = 0.002, simple and multiple model).

Conclusions: Outreach cataract screening was the strongest predictor of increased surgical output. Government and INGDO investment in screening may be most likely to enhance output of county hospitals, a major goal of China's Blindness Prevention Plan.

Visual outcomes of cataract surgery performed by supervised novice surgeons during training in rural China

To assess the outcomes of cataract surgery performed by novice surgeons during training in a rural programme. Design: Retrospective study. Participants: Three hundred thirty-four patients operated by two trainees under supervision at rural Chinese county hospitals. Methods: Two trainees performed surgeries under supervision. Visual acuity, refraction and examinations were carried out 3 months postoperatively. Main Outcome Measures: Postoperative uncorrected visual acuity, pinhole visual acuity, causes of visual impairment (postoperative uncorrected visual acuity<6/18) Results: Among 518 operated patients, 426 (82.2%) could be contacted and 334 (64.4% of operated patients) completed the examinations. The mean age was 74.1±8.8 years and 62.9% were women. Postoperative uncorrected visual acuity was available in 372 eyes. Among them, uncorrected visual acuity was ≥6/18 in 278 eyes (74.7%) and <6/60 in 60 eyes (16.1%), and 323 eyes (86.8%) had pinhole visual acuity≥6/18 and 38 eyes (10.2%) had pinhole visual acuity<6/60. Main causes of visual impairment were uncorrected refractive error (63.9%) and comorbid eye disease (24.5%). Comorbid eye diseases associated with pinhole visual acuity<6/60 (n=23, 6.2%) included glaucoma, other optic nerve atrophy, vitreous haemorrhage and retinal detachment. Conclusions: The findings suggest that hands-on training remains safe and effective even when not implemented in centralized training centres. Further refinement of the training protocol, providing postoperative refractive services and more accurate preoperative intraocular lens calculations, can help optimize outcomes. © 2012 The Authors Clinical and Experimental Ophthalmology © 2012 Royal Australian and New Zealand College of Ophthalmologists.

Cataract surgical outcomes, visual function and quality of life in four rural districts in Vietnam.

BACKGROUND: To evaluate cataract surgical outcomes in four rural districts of Ha Tinh Province, Vietnam. DESIGN: Cross-sectional study. PARTICIPANTS: Post-cataract surgery patients sampled randomly from facilities in four rural districts of Ha Tinh Province >3 months after surgery. MAIN OUTCOME MEASURES: Postoperative visual acuity (VA), visual function and quality of life. RESULTS: Among 412 patients, the mean age was 74.5 ± 9.4 years, 67% (276) were female, and 377 (91.5%) received intraocular lenses (IOL). Nearly two-thirds of patients had no postoperative visits after discharge. Postoperatively, more than 40% of eyes had presenting VA <6/18, while 20% remained <6/60. The mean self-reported visual function and quality of life for all patients were 68.7 ± 23.8 and 73.8 ± 21.6, respectively. Most patients (89.5%) were satisfied with surgery and the majority (94.4%) would recommend surgery to others. One-third of patients paid ≥$US50 for surgery. In multiple regression modelling, older age (P < 0.01), intraoperative complications (P < 0.01) and failure to receive an IOL (P < 0.01) were associated with postoperative VA <6/60. CONCLUSION: Satisfaction with surgery was high, and many patients were willing to pay for their operations. Poor visual outcomes were common; however, and better surgical training is needed to reduce complications and their impact on visual outcomes. More intensive postoperative follow-up may also be beneficial. © 2011 The Authors. Clinical and Experimental Ophthalmology © 2011 Royal Australian and New Zealand College of Ophthalmologists.

Work-related training and the probability of transitioning from non-permanent to permanent employment

It is widely believed that work-related training increases a worker’s probability of moving up the job-quality ladder. This is usually couched in terms of effects on wages, but it has also been argued that training increases the probability of moving from non-permanent forms of employment to more permanent employment. This hypothesis is tested using nationally representative panel data for Australia, a country where the incidence of non-permanent employment, and especially casual employment, is high by international standards. While a positive association between participation in work-related training and the subsequent probability of moving from either casual or fixed-term contract employment to permanent employment is observed among men, this is shown to be driven not by a causal impact of training on transitions but by differences between those who do and do not receive training; i.e., selection bias.

The African Pediatric Fellowship Program: Training in Africa for Africans

Africa has a significant burden of childhood disease, with relatively few skilled health care professionals. The African Paediatric Fellowship Programme was developed by the Department of Pediatrics and Child Health at the University of Cape Town to provide relevant training for African child health professionals, by Africans, within Africa. Trainees identified by partner academic institutions spend 6 months to 2 years training in the Department of Pediatrics and allied disciplines. They then return to their home institution to build practice, training, research, and advocacy. From 2008 to 2015, 73 physicians have completed or are completing training in general pediatrics or a pediatric subspecialty. At 1 year posttraining, 98% to 100% are practicing back in their home institution. The impact of the returning fellows is evident from their practice interventions, research collaborations, and positions as stakeholders who can change health care policies. Thirty-three centers in 13 African countries are partners with the program, and the program template is now followed by other partner sites in Africa. Increasing and retaining the skills pool of African child health specialists is building a network of motivated, highly skilled clinicians who are equipped to advance child health in Africa.

Internationalising the Social Work Curriculum: A Working Toolkit for Higher Education Facilities

This toolkit was collated by social work academics at Queen’s University Belfast (QUB), United Kingdom in collaboration with social work educators nationally and internationally who are committed to the internationalisation of the social work curriculum. The information and examples contained in this document offer a practical guide for the development and evaluation of international opportunities for students and academics. The resources were designed with diverse educational settings in mind for the enhancement of social work learning and teaching.

A Wii Bit of Fun: A Novel Platform to Deliver Effective Balance Training to Older Adults

BACKGROUND: Falls and fall-related injuries are symptomatic of an aging population. This study aimed to design, develop, and deliver a novel method of balance training, using an interactive game-based system to promote engagement, with the inclusion of older adults at both high and low risk of experiencing a fall.

STUDY DESIGN: Eighty-two older adults (65 years of age and older) were recruited from sheltered accommodation and local activity groups. Forty volunteers were randomly selected and received 5 weeks of balance game training (5 males, 35 females; mean, 77.18 ± 6.59 years), whereas the remaining control participants recorded levels of physical activity (20 males, 22 females; mean, 76.62 ± 7.28 years). The effect of balance game training was measured on levels of functional balance and balance confidence in individuals with and without quantifiable balance impairments.

RESULTS: Balance game training had a significant effect on levels of functional balance and balance confidence (P < 0.05). This was further demonstrated in participants who were deemed at high risk of falls. The overall pattern of results suggests the training program is effective and suitable for individuals at all levels of ability and may therefore play a role in reducing the risk of falls.

CONCLUSIONS: Commercial hardware can be modified to deliver engaging methods of effective balance assessment and training for the older population.