Preparedness is not enough: understanding transitions as critically intensive learning periods

OBJECTIVES Doctors make many transitions whilst they are training and throughout their ensuing careers. Despite studies showing that transitions in other high-risk professions such as aviation have been linked to increased risk in the form of adverse outcomes, the effects of changes on doctors' performance and consequent implications for patient safety have been under-researched. The purpose of this project was to investigate the effects of transitions upon medical performance. METHODS The project sought to focus on the inter-relationships between doctors and the complex work settings into which they transition. To this end, a 'collective' case study of doctors was designed. Key transitions for foundation year and specialist trainee doctors were studied. Four levels of the case were examined, pertaining to: the regulatory and policy context; employer requirements; the clinical teams in which doctors worked, and the doctors themselves. Data collection methods included interviews, observations and desk-based research. RESULTS A number of problems with doctors' transitions that can all adversely affect performance were identified. (i) Transitions are regulated but not systematically monitored. (ii) Actual practice (as observed and reported) was determined much more by situational and contextual factors than by the formal (regulatory and management) frameworks. (iii) Trainees' and health professionals' accounts of their actual experiences of work showed how performance is dependent on the local learning environment. (iv) The increased regulation of clinical activity through protocols and care pathways helps to improve trainees' performance, whereas the less regulated aspects of work, such as rotas, induction and the making of multiple transitions within rotations, can impede performance during a period of transition. CONCLUSIONS Transitions may be reframed as critically intensive learning periods (CILPs) in which doctors engage with the particularities of the setting and establish working relationships with other doctors and other professionals. Institutions and wards have their own learning cultures which may or may not recognise that transitions are CILPS. The extent to which these cultures take account of transitions as CILPs will contribute to the performance of new doctors. Thus, these findings have implications for practice and for policy, regulation and research.