The Virtual Continuity in Learning Programme: results

The Virtual Continuity inLearning Programme:resultsEleanor Wood and Simon Tso, Academic Department of Medical and SurgicalGastroenterology, Homerton University Hospital NHS Foundation Trust, London, UK

SUMMARYBackground: The implementationof the European Working TimeDirective and specialty-drivencare has resulted in the loss ofcontinuity of patient care, andthus a loss of continuity inlearning. We proposed a potentialsolution to this fragmentation ofjunior doctor workplace learningin the Virtual Continuity inLearning Programme (VCLP). TheVCLP enables the doctor to followthe virtual patient journey (of anactual patient who is no longerunder their care) using the VirtualConsulting Room (VcR), and tounderstand the rationale behindclinical decision making prior tocompleting their case-based

discussion (CbD) work-basedassessments.Method: Fifty-seven out of 62(92%) of foundation doctors(Homerton University Hospital,London, UK) consented to partic-ipate in the study. Web-trackingsoftware was used. Fifty-three outof 57 (93%) doctors completed aninitial questionnaire. Twenty-nineout of 57 (51%) doctors returneda follow-up questionnaire6 months later. Eleven doctorswere interviewed in three focusgroups: the VcR user group; theVcR non-user group; and a mixedgroup. The data was analysedqualitatively.Results: Tracking showed33.3 per cent (19 ⁄ 57) of doctors

used the VcR over a 6-monthperiod. Interestingly doctors usedthe VcR in a range of situations,not solely as instructed. Resultsenabled us to understand howdoctors learn and their perceptionof using the VCLP to support theirlearning and completion of work-based assessments.Discussion: Foundation doctorsuse the educational resourcesavailable, including the VcR, tohelp structure their workplacelearning. The majority of VcRusers found it particularly usefulfor just-in-time learning. TheVCLP offers support to juniordoctors learning during theirpreparation for case-baseddiscussion.

The VCLPenables the

doctor to followthe virtual

patient journey

Simulatedlearning

216 � Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 216–221

INTRODUCTION

We recently proposed theVirtual Continuity inLearning Programme

(VCLP) as a potential solution tothe fragmentation of workplacelearning for junior doctors.1 Usingthe Virtual Consulting Room (VcR;Figure 1),2 the electronic patientrecord (EpR) and case-baseddiscussion (CbD) work-basedassessments (WBA), the VCLPbrings together the actual andvirtual patient journey to provideon-the-job learning for founda-tion doctors.

Foundation doctors are intheir first or second postgraduateyear of training in the UK. Theyhave to undertake a variety ofWBAs, including a minimum of sixCbDs per year. The VcR is passwordprotected and accessed via thehospital intranet, i.e. whilst atwork. It provides a step-wiseapproach to learning (Figure 2)that allows doctors to appreciatethe rationale behind clinicaldecision making prior to com-pleting their CbDs.

Please refer to our previousarticle for a full description of theVCLP and study method.1

METHODS

ParticipantsFifty-seven out of 62 (92%)foundation doctors from theHomerton University Hospital

consented to participate in thestudy. They were working inemergency medicine, medicine,surgery, paediatrics, psychiatryand general practice.

QuestionnairesNinety-three per cent (53 ⁄ 57) ofthe doctors completed an initialquestionnaire (Q1; September2009), and 29 of the 57 (51%)returned a completed follow-upquestionnaire 6 months later (Q2;March 2010).

Web-tracking softwareWeb-tracking software was usedto monitor VcR usage.

Focus group interviewsSemi-structured interviews wereconducted within 2 weeks ofcompletion of Q2 (see Box 1). Aconvenience sampling strategywas used. Five out of 18 (28%)

VcR users and six out of 39 (15%)non-users were interviewed inthree focus groups (VcR usergroup, non-user group and amixed group). The interviewswere videotaped and fully tran-scribed. The data were analysedqualitatively.

RESULTS FROM THEQUESTIONNAIRE

Learning from the patientjourney

The duration of patient careTwenty-two per cent of doctorsindicated that the average timetheir patients would remain undertheir care was ‘less than 24 hours’.

How frequently doctors follow-uppatient journeysFifty-three per cent of doctorsresponded that they ‘Never’ or‘Rarely’ seek information on apatient’s progress after the pa-tient is transferred from their careto another team.

Doctor’s perceived educationalusefulness of different learningmethodsSixty-six per cent of doctors rated‘Following a patient’s progressafter discharge from their care’ asa ‘Mostly useful’ or ‘Very useful’learning method, 30 per centrated it as ‘Neither useful or notuseful’ and 4 per cent rated it as‘Mostly not useful’ or ‘Not usefulat all’.

HomeSearch

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Patient journeysPatient journeys

Figure 1. The Virtual Consulting Room: ‘Patient journeys within Hepatology’. [Reproduced with the

permission of University College London Biomedica (UCLB) & Royal Free Hampstead NHS Trust.]

The VCLP bringstogether theactual andvirtual patientjourney toprovide on-the-job learning

� Blackwell Publishing Ltd 2012. THE CLINICAL TEACHER 2012; 9: 216–221 217

In descending order, the per-centage of doctors who have ratedthe educational usefulness ofother learning methods as ‘Mostlyuseful’ or ‘Very useful’ are asfollows: ‘Reading about a patient’scondition in a book or printedjournal’ (98%), ‘Clerking a patienton admission’ (94%), ‘Readingabout a patient’s condition usingan online resource’ (94%), ‘Pre-senting a case on ward round or inclinic to a senior colleague’(87%), ‘The process of a CbD witha senior’ (77%) and ‘Preparing acase for a CbD’ (66%).

Virtual Consulting Room as aworkplace learning tool

Doctor’s perceived educationalusefulness of the Virtual ConsultingRoomThirty-four per cent (10 ⁄ 29; Q2)of doctors rated ‘Read up aboutpatient journeys in the VcR’ as a‘Mostly useful’ or ‘Very useful’learning method, 21 per centrated it as ‘Neither useful or notuseful’, 4 per cent rated it as‘Mostly not useful’ or ‘Not usefulat all’ and 41 per cent did notprovide a response.

Undertaking case-baseddiscussion work-basedassessments

Case-based discussionsDoctors completed an average oftwo CbDs over a 2-month period(Q1), and an average of fourCbDs over a 6-month period(Q2). Thirty-six per cent (19 ⁄ 53)and 7 per cent (2 ⁄ 29) of doctorsindicated that they had notcompleted any CbDs within thefirst 2 months (Q1) and6 months (Q2) of starting theVCLP, respectively. Thirty-eight

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Figure 2. A patient journey within the Virtual Consulting Room. Information has been exposed after rolling the cursor over the ‘blood test’ node.

[Reproduced with the permission of University College London Biomedica (UCLB) & Royal Free Hampstead NHS Trust.]

Doctorscompleted an

average of twoCbDs over a 2-month period


per cent (11 ⁄ 29; Q2) ofresponding doctors indicatedthat they have used the VcRwith CbDs (i.e. as recom-mended).

Web-tracking resultsTracking showed 33.3 per cent(19 ⁄ 57) of doctors used the VcRover a 6-month period. The aver-age number of logins per user wasfive (range 1–17, median 2,standard deviation 5.27). Theaverage time duration spent perlogin was 3.5 minutes (range fromless than 1 to 10.6, median 2.3,standard deviation 2.7).

Four (4 ⁄ 19; 21%) doctors usedthe VcR less than twice. Fifteen(15 ⁄ 19; 79%) doctors used theVcR two times or more (these wereclassed as repeated users of theVcR).

RESULTS FROM THEINTERVIEW

Theme: the desire to learn fromthe patient journeyDoctors expressed their desire tolearn from the patient journey,but many raised concerns aboutthe loss of continuity of patient

care resulting from frequentmovement of patients away fromtheir ward (Box 2, quote 1). Mostresponded by using variousmethods to follow-up patientprogress (especially methods thatwould enable them to appreciatethe clinical reasoning behindpatient management steps).However, some doctors reportedthey do not follow-up any pa-tients (Box 2, quote 2). Spendingtime on performing inappropriateduties was reported to have af-fected their workplace learning.

Theme: consolidatingworkplace learningThe doctors used learning toolssuch as textbooks, online re-sources, journals, local and na-tional guidelines, and the VcR tosupplement their workplace learn-ing. They tend to consolidate theirworkplace learning and prepare forCbDs at home (Box 2, quote 3).

Theme: using the VirtualConsulting Room as aworkplace learning toolDoctors used the VcR in a range ofsituations, such as for everydaylearning (Box 2, quote 4), just-in-time learning (e.g. prior to con-

sultant ward rounds; Box 2,quotes 5 and 6), making or veri-fying their patient managementplans (Box 2, quote 7) and toprepare for CbDs (Box 2, Quote 8).

Doctors reported that using theVcR encouraged reflective practiceand helped them deal with diag-nostic uncertainties (Box 2,quote 9). The stepwise patientjourneys within the VcR werenoted to be particularly useful,and helped them appreciate whenit is appropriate to seek seniorhelp (Box 2, quote 10). Barriers tousing the VcR include the lack ofVcR access outside the hospitaland the need for more computerstations in the workplace.

Theme: the difficulties withundertaking case-baseddiscussionsSome doctors expressed difficul-ties in performing CbDs. There iswide variability in terms of howCbDs are undertaken (Box 2,quotes 11 and 12).

DISCUSSION

Uptake of the VirtualConsulting RoomMulti-centre studies evaluatingthe use of e-learning programmeshave shown enormous disparity intheir registration rates.3–7 OurVcR uptake rate of 33.3 per cent(by 6 months) is comparable withour earlier general practice pilotstudy,3 and compares favourablywith the uptake rate (by6 months) of 5.3 per cent(192 ⁄ 3632) reported by a Danishstudy that looked at the uptake ofa sophisticated e-learning pro-gramme.7

Factors potentially limitingthe uptake and use include: (1)the small number of CbDs (averagefour) undertaken per doctor, witha small percentage not complet-ing any CbDs by the end of thestudy; and (2) a lack of access tothe VcR and EpR out of workinghours, times at which the doctorsindicated that they tend to pre-pare for CbDs.

Box 1. Focus group interview questions

• How does the loss of continuity of care affect your learningneeds? And how have you tried to overcome this learningproblem?

• Did you use the VcR with CbDs as suggested?

• Have you used it (the VcR) outside of doing a CbD? What for? Inwhat context?

• Did you find it (VcR) useful?

• What are the barriers to using the VcR?

• What other learning materials did you use to do your CbDs? Dothey make preparation for CbD assessment a more educationallyuseful experience? Why?

• Do these learning methods satisfy your learning needs andsupport your clinical decision making?

• Are there any barriers to completing CbDs in the way that isrecommended by the foundation programme?

• Do you think the VcR will be a useful teaching tool for teachingjunior doctors?

Doctorsreported thatusing the VcRencouragedreflectivepractice


How is the Virtual ConsultingRoom being used?Doctors accessed the VcR in arange of situations, not solely asinstructed. Our impression is thatmost VcR users accessed the VcRfor just-in-time learning at work,in particular when alternativelearning resources are not imme-diately available.

The barrier factors to using theVcR and the factors associatedwith its repeated use are described

in Figure 3. Our findings echoedthe results from the literature,reporting that learners’ perceivedbarriers to using e-learning pro-grammes are often associated withindividual factors such as lack oftime, motivation, self-disciplineand technical problems.6

The educational and clinical roleof the Virtual Continuity inLearning ProgrammeThe VCLP is a unique work-basedlearning programme. It has a place

in enhancing the learning processof CbD preparation. The VcR has amore general role in providing on-the-job learning for doctors interms of just-in-time learning, andin some situations providing man-agement plans for patient care.Following the virtual patient jour-neys offers direct access to evi-dence-based specialist knowledge.In addition to providing supportfor doctors in terms of under-standing the clinical decision-making process, it also allows users

Box 2. Selected quotations from the focus group interviews

Quote 1: ‘Patient will come along with a certain problem and get transferred tomorrow somewhere elseand then we are all kind of unsure, oh what’s happened to them’.

Quote 2: ‘I don’t follow-up anyone’.

Quote 3: ‘What I tend to do reading about patients I like to do it at home on my own time. I don’t want todo it at work. I feel like I should be attending to the patients’.

Quote 4: ‘I used it for my everyday learning as well, so when a new patient came in I would go to VcR andsee what the plan would be for the patient’.

Quote 5: ‘Sometimes you are asked to discharge a (malaria) patient…no one else can tell me how long youtreat them for because you can’t find any protocol. Using it [VcR] to make specific treatment andmanagement’.

Quote 6: ‘The reason I used it [VcR] was because I had never clerked in a lady with jaundice before. I had arough idea from my medical studies but there is a great big gap between being a medical student andbeing a doctor, so I did manage to clerk and come up with a management plan. I used it [VCR] to confirmthat I had asked all the important questions, and if I hadn’t I went back and asked them, and then also ifmy management plan was appropriate in the context of how she presented. I tried to do that because itwas for the post-take ward round and I tried to do that before the consultant saw the patients. So I didas much as I could do before I presented’.

Quote 7: question, ‘Did you use it [VcR] to alter any clinical decisions that you made?’; response, ‘I meanif I looked at it and I saw the recommended treatment was this, and the recommended investigationswas this, then I would include that in the treatment plan’.

Quote 8: question, ‘Did you use it [VcR] with any CbD?’; response, ‘Yeah, [used it with] about four CbDs’.

Quote 9: ‘So certainly it [VcR] helps reflective practice towards clinical decision making and to themedical aspects of the case. It’s most helpful for the diagnostic uncertainties a junior doctor faces’.

Quote 10: ‘I think what is good about the VcR is that it takes you through the stepwise process (Figure 2)of how you would work this patient up…the VcR will take you through the initial management and thenget to the highly invasive procedure, and I find that highly useful in thinking about ok when do I need tocall a senior or when do I need to take the next step’.

Quote 11: ‘I like the concrete aspect of the guidelines incorporated in the VcR that perhaps you don’t getso clear a picture of when you are discussing [a case during CbD]’.

Quote 12: ‘...the consultant doesn’t necessarily want to talk about the process of how you worked thepatient up but more about the [condition]’.

Most VcR usersaccessed the

VcR for just-in-time learning at

work


to learn about the natural historyof disease. This is particularlyimportant for doctors who workwithin an environment with shortpatient stays, who are not proac-tive in following-up patients orwho are working part-time.

Case-based discussionsThe CbDs are often prepared athome, and are a small but usefulpart of the continuing educationof foundation doctors. Some haveencountered difficulties whileundertaking CbDs. The VCLP canprovide a framework for CbDpreparations, but would be evenmore useful if the VcR could bemade accessible from home.

Strengths and limitationsOur qualitative data was drawnfrom a small convenience sample.The Q2 return rate was low rela-tive to that of Q1. We haveminimised recall bias by conduct-ing the interviews soon after thefollow-up questionnaire.

CONCLUSION

Foundation doctors use the edu-cational resources available,including the VcR, to help themstructure their workplace learn-ing. The VCLP is unique in that itoffers educational support tojunior doctors in the form of

on-the-job (particularly just-in-time) learning and during CbDpreparation, but also has aclinical role in terms of support-ing patient management.

REFERENCES

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between primary and secondary care.

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5. Sisson SD, Hughes MT, Levine D,

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based curriculum on postgraduate

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Fremont P, Cauchon M, Desmartis M.

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7. Waldorff FB, Steenstrup AP, Nielsen B,

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Corresponding author’s contact details: Simon Ho Yuen Tso, Academic Department of Medical and Surgical Gastroenterology, HomertonUniversity Hospital NHS Foundation Trust, London, UK. E–mail: [email protected]

Funding: None.

Conflict of interest: None.

Ethical approval: The research project proposal was discussed with the local ethics committee and it was concluded that formal ethics

approval was not deemed necessary. Written and informed consent were obtained from the participants, the anonymity of participants

was guaranteed, anonymised questionnaires were used and there was no potential harm to the participants.

doi: 10.1111/j.1743-498X.2012.00551.x

62 Foundation doctors were invited

Not included in the study

Yes (57/62)Barriers to using the Virtual ConsultingRoom the first time: --Lack of motivation-Having other priorities-Need password to access-Accessibility-Lack of resources-Doctors did not complete any case-baseddiscussions

No (38/57)

Consent to participate in the study?

Accessed the Virtual Consulting Room?

Yes (19/57)

Barriers to continuing to use the Virtual Consulting Room: --Lack of need to use the Virtual Consulting Room-Did not find the Virtual Consulting Room helpful-Did not suit the doctor’s learning style-Availability of alternative learning resources -Doctor did not complete more case-based discussions

Continued to use the Virtual Consulting Room?

Yes* (15/19)

Factors associated with repeated use of the Virtual Consulting Room: --Suits the learning style of the doctor -The doctor is highly motivated-Found it helpful-Perceived the Virtual Consulting Room to be useful and reliable-Availability of time and resources

No (5/62)

No (4/19)

Figure 3. Barriers to using the virtual consulting room and factors associated with its repeated use

The VCLP offerseducationalsupport tojunior doctorsin the form ofon-the-joblearning


The Virtual Continuity in Learning Programme: results

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