Building reflective spaces for junior doctors to promote ethical, legal and professional learning relating to clinical practice

Concerns have been raised surrounding the training of Foundation Doctors on the ethical, legal and professionalism (ELP) aspects of clinical practice, leading to some to claim a degree of educational neglect. Foundation Doctors are junior doctors in the United Kingdom within the first 2 years of their medical career since graduating from medical school.


| BACKGROUND
Continuing ethical, legal and professionalism (ELP) learning beyond medical school has long been a pressing concern. 1 There have been calls to ensure that the formal teaching within the UK foundation training programme includes sufficient content on ELP topics 2 for Foundation Doctors (FDs), who are within the first 2 years of their medical career since graduating medical school. Research shows that FDs have trouble grappling with ELP issues in clinical practice 3 as they transition from medical student to health care professional, 4 and yet still operate as both learner and clinician 5 as they rotate around wards and specialities as part of their training. However, it is acknowledged that support and reflective opportunities for FDs when facing ELP issues in practice is limited, due to a lack of senior role models to serve as moral and practical guides, 5 and the limited training and educational spaces. Consequently, doctors and ethicists alike have raised concerns over a degree of educational neglect 6 given the dearth of dedicated educational resources tailored for FDs and their continued learning around ELP. 7,8 In 2021, the UK Foundation Programme Office (UKFPO) released an updated curriculum for all UK Foundation Schools to follow, which includes ethics and law as one of the three higher order learning objectives central to the curriculum.
In response to this, Lancaster University and Health Education England North West (HEE NW) introduced Building Reflective Spaces for Foundation Doctors: Thinking Ethically, Legally and Professionally, a series of training materials specially created to meet the ELP training needs of FDs. The ambition underpinning the training series was to promote and encourage ELP sensitive, aware and reflective FDs, whereby they are attuned to the ELP aspects of their everyday clinical practice, which informs reasoned and transparent decision making and actions; such capabilities in doctors have been deemed beneficial for health care organisations. 9 The aims for each training pack within the series varied according to the ELP theme (see Table 1).

| APPROACH
When designing the Building Reflective Spaces series, we took into account the perspectives and needs of both the FDs and those tasked with delivering the Foundation Programme within hospitals, trusts and schools. The in-depth focus of the UKFPO curriculum on ELP alongside the range of ELP topics that FDs stated they wished to receive training on as a FD, 10 meant that multiple training packs were required to form a series to provide a reflective space for FDs to consider the ELP aspects of their everyday clinical encounters areas (see Table 2). The training packs intentionally built upon the ELP learning the FDs gained during medical school and therefore aimed to advance their knowledge, understanding and learning in these areas, accepting that there is extensive and ongoing debate over whether knowledge of ELP influences and informs practice. 9,11 Large-scale and longitudinal studies are needed with health care professionals in order to fully explore the impact of ELP training on practice.
The training packs were designed to be delivered by clinical colleagues who may or may not have formal qualifications on ELP, or by non-clinical colleagues, such as academics at local medical schools.
The content of the training packs were mapped against the new UKFPO (2021) foundation professional capabilities, for example, continuity of care, upholding the values, ethics and law, as well as the General Medical Council Generic Professional Capabilities, thereby illustrating the need for the training to the FDs. The content of each training pack was drawn from research studies (see Table 2) and included a range of media to support learning including blogs, podcasts and television programmes. The training packs provided discrete training opportunities for FDs around a specific ELP theme, and therefore, it was not necessary for all five training packs in the series to be used by a hospital trust or the packs to be used in a particular order as the packs did not require prior learning on the topic. That said, the ELP content in each pack were purposively different and included a wide range of concepts, theories and frameworks so that the ELP learning of FDs developed and expanded with each training pack.
Each pack included a slide pack and a facilitator's guide on how to T A B L E 1 Examples of the suggested aims and content available for a selection of the ELP training packs.  build the training session. The facilitator would deliver the training, which could entail lecturing, and facilitating small group work and large group discussions, depending on which activities they choose to include.

| EVALUATION
The

| IMPLICATIONS
There have been a number of successes, surprises and impacts resulting from the piloting of the training materials (see Table 3).
Success 'highlights' were the FDs appreciated the range of resources used in the training, for example, podcasts, qualitative extracts from research studies and the combination of legal cases with ethical frameworks: T A B L E 3 Successes, surprises, impacts and reflections of ethics, law and professionalism training pilot.

Successes Surprises Impacts Reflections
Foundation Schools appreciated readily available training materials that were flexible in terms of time available, delivery mode and so on particularly during a pandemic when face to face teaching was restricted.
Requests from trusts to develop additional training packs on topics suggested by facilitators and/or the FDs.
In some trusts, the training packs are now a fixed feature of their upcoming Foundation training programmes.
Some facilitators, when agreeing to pilot the training materials, requested the opportunity to ask questions to the design team when using the materials to build their training session. However, an aim of designing the training packs was to empower trusts by providing the resources online in the future. In response, these facilitators were guided to the facilitator's guide provided in each training pack and at that stage to return to the design team with any questions. By trusts piloting the training materials, unforeseen possibilities of the training packs to be used to generate an interprofessional learning opportunity.
Trusts have asked for more training packs to incorporate into their Foundation training programme.
While most FDs reported enjoying the reflective tone of the training sessions, some FDs craved the inclusion of 'practical tips' and 'reference to clinical practice'. In future training packs, facilitators will be encouraged to promote explicit discussion with FDs over how the key messages in the training session can inform their future clinical practice, that is, what will you do differently as a result of this training session?
FDs appreciated having dedicated time and space to reflect on their own and others clinical practices, as well as having the opportunity to share their experiences, and engage with their peers at this stage of their training.
The training packs were also used as a way of responding to points raised in reports from regulators, such as the Care Quality Commission inspections.
FDs appreciated ethics, law and professionalism training on topics that were identified by their peers as worthwhile.
FDs also valued receiving training that was tailored to meet their unique needs given their position in the medical hierarchy.
The article on which the session was based shared some surprising insights in to the perception and prac- They also made links between the messages delivered in the training to shifts in their practice and influencing their approach to patient management.
We have continued to design training packs in order to build a programme that can meet the ELP training needs for FDs.
Consequently, the packs could form the basis of a minimum curriculum as recommended elsewhere for the 2-year foundation programme. 10

| Next steps
The piloting of the training packs is ongoing to allow for newly designed training packs to also be tested and evaluated. Additional training packs will be designed based on topics identified by FDs and facilitators. Learning modes, such as video clips and simulation experiences are being considered to provide diversity within new training packs. Open access options to make the training packs easily accessible by foundation schools once the pilot has completed are being explored. In recognition of the value of experiencing learning to share learning, we will be holding continuing professional development events, which will involve the materials in the training packs being T A B L E 4 Successful facilitation factors for similar training initiatives.

Design principle Measure
Flexibility Foundation Schools appreciated having training materials that are readily available, and can be adapted according to time available, and delivery mode etc.
User engagement and co-construction The design collaboration for the training programme included FDs as they were able to provide authentic case studies for discussion and also ensure the materials were pitched as Foundationlevel experience.
Needs analysis FDs appreciated ELP training on topics that were identified by their peers as worthwhile 5 and was tailored to meet their unique needs given their position within the medical hierarchy. 2 used by senior doctors so they experience ELP training, as well as reflecting on how they may use the packs for training FDs in their trusts.

| Barriers and facilitators
There were various elements that worked well that suggest principles when designing a similar training programme in the future, that is, flexibility, needs analysis and user engagement (see Table 4). However, some facilitators reported that building a session took longer than they anticipated, perhaps as a result of not being ethically or legally qualified, or exploring a topic they had not taught previously.
On reflection, facilitators could be provided with an indicative timeframe, for example, 3-4 h to build a session in order to promote allocating sufficient preparation time.

| CONCLUSION
The continuing interest from both FDs and foundation schools in Building Reflective Spaces programme supports the calls for ELP training to continue beyond medical school. 1. Furthermore, it reinforces the idea of FDs holding a unique position within medical training, 3-5 and therefore, a targeted training programme on ELP is both warranted and much desired.
The continuing interest from both FDs and foundation schools in Building Reflective Spaces programme supports the calls for ELP training to continue beyond medical school.