Learning and teaching occurs predominantly in the workplace, with protected teaching time and private study being used to consolidate the learning that has occurred through practice. Workplace learning is experiential, acquired through the delivery of care under supervision, and in the form of supervised learning events (SLEs). Foundation doctors are encouraged to engage in reflective practice and self-directed learning from patients, clinical opportunities, books, journals and electronic learning materials, including e-Learning for Healthcare as described in the foundation programme curriculum 2016 resource. Foundation doctors are also expected to learn both from and through teaching, and 'learning to teach' is very important.

Foundation doctors need to recognise that whilst protected teaching time is an important part of their education, it is the workplace that offers the majority of clinical and professional learning opportunities. It is also critically important that foundation doctors recognise that they have professional and personal responsibility for their own learning. This includes attending structured educational sessions and undertaking SLEs wherever possible. Organisations, foundation schools, consultant and general practitioner trainers all have roles but these should be seen as an adjunct to that personal responsibility.

Foundation doctors should also learn by observing how other healthcare professionals (role models) perform both as individuals and as members of clinical teams. They should learn about modes of engagement and interaction with patients and other professionals, observe practical skills and consider how formal knowledge is applied.

Foundation doctors should reinforce learning by thinking about both good and bad aspects of their work with emphasis on how they might act in the future if faced with a similar situation in particular what they might do to ensure the best outcome. Reflective writing has been shown in other professions to lead to deeper learning and better practice. Doctors too can record reflections on their learning experiences in the e-portfolio as part of their evidence of commitment to the educational process. Personal reflection may be reviewed with/by clinical and educational supervisors and discussion of reflections with senior colleagues form an important part of the foundation doctor's professional development.

Although some clinical experiences may seem repetitive, they still present a learning opportunity. Such experiences may also constitute important contributions to patient safety and care, a crucial aspect of practice as a foundation doctor. Revisiting aspects of practice remains an integral component of the spiral curriculum that underpins foundation training. It is important to appreciate and experience variation within common conditions, which will need to be considered for each individual patient/situation. This will create greater expertise and allow foundation doctors to progressively take more management responsibility in acute and long-term care.

 

Clinical learning experiences

Foundation doctors and their trainers should recognise the importance of maximising the wide variety of learning opportunities in the clinical workplace and undertake SLEs to capture this. supervised learning events (SLEs) must be appropriate to the foundation doctor's level of experience and the nature of learning opportunities afforded by their current working environment (table 3).

Table 3. Examples of work-based learning and teaching opportunities

  • Work as a medical professional, including clinical practice, attending meetings and documenting care
  • supervised learning events (SLEs)
  • Accounts by patients, service users and carers of their experiences
  • Analysis of care scenarios supported by literature reviews
  • Involvement in Quality Improvement and audit projects
  • Audio/video recording of personal practice or a colleague's practice
  • Computer-controlled simulator
  • Discussion of one's own or another's practice
  • E-learning: e-Learning for Healthcare, BMJ Learning, FP Curriculum 2012 Resource
  • Group discussion of typical cases
  • Mock assessments
  • Narrative of one's own or someone else's case
  • Observation of and reflection on someone else's work and practice
  • Review of clinical guidelines or protocols
  • Review of patients' case notes (individual or team)
  • Simulated patients and/or colleagues
  • Human factors training
  • Skills laboratory
  • Undertaking a supervised leadership activity such as leading the multi-disciplinary team meeting

Source: Modified from Fish and Coles (2005)

The learning opportunities and experiences available vary between placements and rotations. It is recommended that foundation school directors (FSDs) map their rotations to the curriculum and familiarise themselves with areas in the curriculum which may require additional input to deliver (Table 4).

Table 4. Examples of potential difficulties related to delivery of the curriculum

  • Organisation and allocation of work by an F2 within the team during placements where there is no F1 doctor
  • Exposure to managing long-term ill health in rotations which do not include general practice, community medicine or outpatient clinics
  • Exposure to acutely unwell patients in rotations which do not include at least four months in acute/emergency medicine
  • Assessment of proficiency in an acute setting
  • Senior supervision and discussion of discharge planning, discharge summaries and ongoing medication (drugs to take out/away from hospital)
  • Adequate demonstration of progress in relationships with patients and communications skills.

Foundation school directors should consider alternative mechanisms to cover elements of the curriculum, which may not be encountered in daily practice. These could be included in programmed educational activities where emphasis might be placed on topics that are challenging to deliver locally, or on concepts which are particularly important or difficult to understand. Whenever possible, novel opportunities should be used to deliver these (table 5).

Table 5. Additional opportunities to deliver and assess curriculum coverage

  • Simulation training in practical techniques and human factors (organisational and team working ability)
  • Supervised clinical practice directed at key areas
  • Formal teaching programme tailored to the local educational needs
  • Demonstration of appropriate learning/assessment online using local and national resources such as e-Learning for Healthcare
 

How practical procedures are learnt

Practical procedures start to be learnt as undergraduates and may be a focus during clinical assistantships in the final year. It is expected that medical students and foundation doctors start to learn procedural skills on simulated models/manikins prior to undertaking the procedure on patients. Students and doctors are encouraged to recognise that the ability to perform a practical procedure increases with time, repetition and experience. Although the primary purpose of direct observation of procedural skill (DOPS) in foundation training is the doctor patient interaction, some trainees may also wish to use DOPS and reflective practice to demonstrate progression of their practical ability.

The following steps may be taken:

  • Reading the theory, or studying virtual training packages on the internet or DVD
  • Using a skills laboratory (where available)
  • Learning in simulation centres with simulated patients
  • Observing first-hand
  • Being observed doing the procedure by a competent practitioner with relevant experience of the procedure.
 

Technology enhanced learning

Evidence from recent UK studies has shown that simulation facilities and e-learning provides foundation doctors with valuable opportunities to deepen their understanding of the importance of communication skills, human factors and teamwork in clinical practice in addition to procedural skills.

Foundation doctors should learn and rehearse skills using simulated environments and other technologies as part of a managed learning process. They should be judged to be safe in this environment before they undertake a supervised procedure on a patient.

 

Teaching

Foundation doctors will be expected to acquire and develop the skills needed to deliver teaching and mentoring effectively. This includes understanding the basic principles of adult learning. They must recognise that teaching skills also apply to their clinical practice e.g. when explaining illness to patients/relatives/carers. The acquisition of teaching skills should be documented in the e-portfolio and feedback should be sought on the quality of teaching using the 'developing the clinical teacher' - supervised learning events (SLEs) as well as from those receiving the teaching.

Consideration should be given to developing effective presentation styles including approaching teaching sessions from the perspective of the learner. This should include reflection on the learners' (including patients/relatives) needs. They should understand different approaches such as small group and large group learning and when each is most effective. When teaching groups, foundation doctors should demonstrate appropriate use of teaching aids and organise the environment to optimise interaction. They should facilitate group discussion to allow others to express their views. Additional opportunities to develop presentation skills exist in departmental meetings/audit/grand/ward rounds.

Doctors must learn to give and receive feedback and perform assessments. Foundation doctors will contribute to the assessment or review of students and other colleagues with whom they work. They need to understand the underlying principles of coaching and theory of feedback e.g. Pendleton model (table 6). They should always observe a learner's performance before commenting on any aspect of it, and then give relevant feedback in a structured, sensitive, constructive and positive way.

Table 6. Principles of delivering feedback adopted from Pendleton's rules

  • Observer ensures that the learner wants and is ready for feedback.
  • Allow the learner to give comments/background to the material that is being assessed
  • The learner states their strengths / what was done well.
  • The observer reinforces these and provides further examples.
  • The learner identifies how performance could be improved.
  • The observer reinforces these and adds further constructive suggestions for improvement
  • An action plan for improvement is devised.

Foundation doctors may take on a supervised educational role, once they have received approval for this, for example in teaching and supervising medical students on a ward or in an outpatient setting. When teaching, they must always treat patients and other learners with respect, including seeking patients' permission before any teaching session involving them takes place. Doctors should treat requests for help positively and help those they are teaching to become progressively more independent.

 

Study leave during foundation training

F1 doctors do not have access to study leave, although there may be opportunities for 'career taster' sessions in F1. Refer to the Reference Guide.

F2 doctors will be encouraged to take study leave to support their learning in relation to the curriculum (refer to the Reference Guide). This might include:

  • Attending courses relevant to the foundation programme e.g. to achieve training in advanced life support
  • Sampling other 'taster' career alternatives that were not available within their F1 rotation e.g. public health, laboratory-based specialties, etc.