Impact of a structured training and support program on junior doctors’ participation in clinical audits

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CATS Program Initiative The clinical audit Training and Support (CATS) Program is an initiative to educate interns and promote their participation in Clinical Audits and quality improvement through the implementation of a learner centred curriculum that values self-directed, experiential and situated learning. The CATS program was to run over a period of 3 months. During that time, the interns enrolled in the program were expected to have successfully completed one PDSA cycle of clinical audit. Methodology A non-randomized quasi experimental pre-test post-test study was designed to assess the effect of the CATS program in improving the knowledge, attitude and behaviour of the interns towards clinical audits and quality improvement. This was a survey study using questionnaire prior to the initial lecture and 3 weeks later. A voluntary convenient sampling was used as the CATS program was a non-mandatory training initiative for the interns. Results There were 31 and 30 Interns who rotated through various medical and surgical jobs. Following ethical approval, the initial lecture on the audit was delivered on 08.09.22, and the post-test was 2 weeks later. The post-test knowledge score following the initial lecture was significantly higher than the pre-test score. The attitude of interns towards clinical audit and quality improvement were neutral and remained unchanged following the CATS initiative. Higher proportion of interns were actively involved in clinical audits following the CATS initiative. Conclusion Audit-related teaching to junior doctors at the beginning of their career as hospital doctors can help them recall audit-related knowledge and learn local quality improvement policies. Although junior doctors want to be involved in quality improvement initiatives, their attitude towards clinical audits remains neutral due to lack of time, training and support. A structured training and support program for junior doctors promotes their participation in quality improvement initiatives and improves service outcome measures. Hospital Medicine Clinical Audit Structured Training CATS Program Figures Figure 1 INTRODUCTION Clinical audit is the measurement of clinical outcomes or process against a well-defined standards set on the principles of evidence based medicine with an aim to improve the quality of patient care. (Esposito & Dal Canton 2014 ) Clinical Audits which are quality improvement measures, and one of the Seven Pillars of clinical governance are vital aspects of clinical governance and continual service improvement in medicine (Limb et al. 2017 ) Clinical Audits not only improve patient outcomes, but also promote awareness about the clinical standards amongst practicing clinicians. (Thomson O’Brien et al. 2000 ) The Irish Medical Council in its Guide to Professional Conduct emphasizes the importance of Clinical Audits in evidence based medicine and the need for medical practitioners, including junior doctors to participate in clinical continuing medical education.(IMC 2009 ) It is widely believed that newly qualified junior doctors may be able to identify and improve clinical practices which more experienced doctors often take for granted (Gaiser 2009 ) There is an increasing focus on junior doctors potential to improve healthcare outcomes and empowering them as agents for change. (Agents for change 2022 ) Newly qualified doctors are often able to recognize gaps in service provision, but soon they adapt to fit within the status quo culture. Therefore, the initial period after graduation is vital in making junior doctors to become champions of change before they become fully embedded into the status quo. (Holland et al. 2010 ) Although the junior doctors views on clinical governance differ, widely. Intense support the principle of audit and are keen to participate in Clinical Audits. (Nettleton & Ireland 2000 ) Every year in Ireland more than 1200 medical graduates make transition from being a medical student to being an intern predominantly in hospital settings. Despite the large number of medical graduates who start their career as interns only a few interns are involved in Clinical Audits and quality improvement due to the lack of audit related teaching and a structured program to guide interns through the audit process (Greenwood et al. 1997 ) Nonetheless, junior doctors can be trained and supported in quality improvement skills, which can result in real changes in the quality of patient care and outcomes.(Diaz et al. 2010 ) METHODS The CATS program The clinical audit Training and Support (CATS) Program is an initiative to educate interns and promote their participation in Clinical Audits and quality improvement through the implementation of a learner centred curriculum that values self-directed, experiential and situated learning. The intended learning outcomes were identified following the Bigg’s principle of constructive alignment to support learning and teaching. (Loughlin et al. 2021 )The teaching and learning activities and assessment methods were then developed in alignment to the intended learning outcomes to help learners meet their learning outcomes. (John Biggs 2014 ) As the conduct of clinical audit can be seen as an Entrustable professional activity (EPA) with increasing levels of entrustment and decreasing levels of supervision(Jarrett et al. 2018 ) the interns were required to attend a one hour lecture initially on Clinical Audits following which they were given an opportunity to participate voluntarily in the CATS program and those who opted to participate in the cats program, were given time slots for workshops in small groups to identify their audit topics. And then they were linked with mentors who look who supervised 3–4 interns. The interns had the flexibility of meeting with their mentors at their preferred times to discuss their audit ideas and further steps in an informal and relaxed environment. As part of the assessment, the intense were to answer true or false questions. They were also assessed based on their audit proposal, audit analysis and audit presentation submissions with a word limit of 250 words each. The trainers or the mentors were recreated on a voluntary basis with the requirement to have completed a clinical audit project themselves. The mentors guided the interns in the initial audit proposal and data collection and analysis processes with decreasing levels of supervision. The CATS program was to run over a period of 3–6 months, during which time the interns enrolled in the program were expected to have successfully completed one PDSA cycle of clinical audit. The program was run under the supervision of the regional intern coordinator and the local Clinical audit coordinator. The program was to be continued in the forthcoming years following program evaluation and feedback from the interns and the trainers. Research aim To assess the effectiveness of a Clinical Audit Training and Support (CATS) program in improving audit related knowledge, attitude, and participation in Interns. The primary research question was if the structured CATS program was superior in promoting intern attitude and participation in clinical audits compared to previous year Interns who did not have audit related teaching. The secondary research question was if participation in the clinical audit lecture as part of the CATS program improved retention of audit related knowledge at 3–4 weeks. Study design A non-randomized quasi experimental pre-test post-test study was designed to assess the effect of the CATS program in improving the knowledge, attitude and behaviour of the interns towards clinical audits and quality improvement. This was a survey study using questionnaire prior to the initial lecture and 3 weeks later. The questionnaire included True or False questions and rating questions and was delivered in person at the Intern teaching to be completed using pen and paper. Participants The participants were new medical graduates who started as Intern doctors at the proposed study site in July 2022. About 20–25 participants, in the age group 24–34 years, with an equal proportion of males to females were proposed. Inclusion criteria Participant should be an Intern doctor at the study site Participant should attend the mandatory Intern teaching Participant should be able to provide informed consent Participant should be able to answer questionnaires using pen/paper Exclusion criteria More than 2 years’ experience working as a doctor More than 2 clinical audits performed in previous employment or medical school Intended benefits of participation All participants will benefit from a one-hour lecture on Clinical audit. Participants willing to participate in clinical audits will have an opportunity to perform a clinical audit through the non-mandatory CATS program. Participants who complete a clinical audit will be encouraged to present their audits at the regional Clinical audit day and receive a certificate of participation. Participants who complete an audit will gain valuable experience for professional growth and a certificate to support career progression. Improved organizational performance and patient outcomes are the indirect outcomes of the research project assuming improved Intern participation in clinical audits Sampling and sample size A voluntary convenient sampling was used as the CATS program was a non-mandatory training initiative for the interns. 30 interns started internship at the study site on July 2022. Accounting for Interns who are on call, on leave or do not attend intern teaching there usually 20–25 interns who attend the Intern teaching on Thursdays. Therefore, a convenient sample size of 20–25 was chosen for data collection. However, there was a 20% sample attrition proposed due to non-availability of the same subjects at the pre-test and post-test sessions. Hence a final sample size of 15–16 was proposed for the test re-test analysis. The intern doctors had mandatory weekly teachings on Thursdays. The participants were explained about the study, and were given opportunity to ask questions and were recruited to the lecture and CATS programme conditions. As the Audit lecture was delivered during one of the Intern teaching slots, the Intern doctors on duty were expected to be at the intern teaching (Mandatory). However, participation in the CATS programme was voluntary. Selection of participants were not restricted; all Interns at the Intern teaching were provided with the Participant information sheet. The Consent process, Data protection policy and the research aims were discussed, and questions were clarified. Interns willing to participate in the CATS program were expected to provide their phone number. Following the lecture interns who provided their phone number were contacted and linked to their mentors as outlined in the CATS curriculum via WhatsApp. Data collection The interns were provided with a two-sided data collection tool at the initial teaching session. On one side it contained the consent form including participant name and phone number. On the flip side there was a questionnaire that had 3 main sections: The knowledge section of the questionnaire to provide a raw score out of 10 which reflected the audit knowledge of the interns. The beliefs section of the questionnaire with reverse scoring for questions 2,3 and 5 to assess the attitude of Interns towards clinical audits. > 15 – Positive attitude < 10 – Negative attitude The experience section of the questionnaire to quantify the number of Interns involved in the clinical audits. At the teaching session the interns were provided with the PIS first and then they were requested to sign the consent to participate in the research with their name subscribed. Then the Interns were given 10 mins to complete the questionnaire. After that the lecture was delivered by the lead researcher and the local clinical audit co-ordinator. At the end of the lecture interns were advised to complete the willingness to participate in clinical audit section and provide phone number. Thereafter, the interns who were willing to participate in the CATS program were linked to their respective tutors and had training and support as outlined in the CATS curriculum. 2–4 weeks after the initial lecture all interns regardless of whether they participated in clinical audits (CATS) or not, were requested to complete the questionnaire once again following scheduled Intern teaching on a Thursday. Data analysis The survey questionnaire were reviewed for usability, inclusion, and exclusion criteria. Descriptive statistics was to include the number of interns, central tendencies of the knowledge score and attitude score. Inferential statistics was to include Student’s t-test of the pre- and post-audit knowledge, attitude, and experience. Data was to be analysed using SPSS 24.0 software. RESULTS There were 31 and 30 Interns who rotated through various medical and surgival job whike Following ethical approval, the initial lecture on audit was delivered on 08.09.22 and the post-test was 2-weeks later. 21 (70%) Interns were present at the initial audit and all of them participated voluntarily in answering the questionnaire. Later, 20 (67%) interns were present for the post-test and all of them answered the questionnaire. For paired t-test analysis 16 Interns (53%) who participated in the pre-test and post-test were used. The knowledge test score (Table 1 ) of the 16 participants (mean ± SD); at baseline, 2-weeks post lecture and paired differences were 6.2 ± 1.0, 7.4 ± 0.9, and 1.1 ± 0.8, respectively. Paired samples t test indicated that mean difference of paired observations of knowledge test score between baseline and 2-weeks post lecture was statistically significant ( P < 0.001). The post test scores were significantly higher and there were no scores below 5 in the post test. (Fig. 1 ) Table 1 Descriptive statistics of pre-test and post-test scores of interns’ knowledge about clinical audits Audit knowledge score N Minimum Maximum Mean Std. Deviation Pre-test score 16 4.00 8.00 6.2500 1.00000 Post - test score 16 5.00 9.00 7.3750 1.02470 Valid N (listwise) 16 The post test scores were significantly higher and there were no scores below 5 in the post test. (Fig. 1 ). Most interns improved on questions related to the steps involved in the audit cycle and the non-requirement of ethical approval for clinical audits. The Attitude score (Table 2 ) of the 16 participants (mean ± SD); at baseline, 2-weeks post lecture and paired differences were 16.2 ± 3.0, 16.9 ± 2.8, and 0.8 ± 1.2, respectively. Paired samples t test indicated that mean difference of paired observations of attitude score between baseline and 2-weeks post lecture was not statistically significant ( P = 0.18). Though All interns agreed that they wanted to do an audits, the overall attitude towards performing audits was neutral. Table 2 Descriptive statistics of the 5-point Likert scale assessing the attitude of interns towards clinical audits. Attitude towards clinical audits Attitude towards audits N Minimum Maximum Mean Std. Deviation I want to do audit 16 4.00 5.00 4.4375 .62915 Audits are doable 16 2.00 5.00 3.6250 .88506 I will have time for audits 16 2.00 5.00 3.2500 1.06458 I will be supported in audits 16 1.00 5.00 3.3750 1.02470 Audit is my responsibility also 16 1.00 4.00 2.1875 .91059 Valid N (listwise) 16 With regards to Interns quality improvement behaviours (Table 3 ), only 2 interns (6%) performed a clinical audit during their internship in 2021–2022 at the study site. None of the current Interns (2022–2023) were involved in any clinical audits prior to the CATS program. 3-weeks following the initial lecture and the CATS program 8 Interns (27%) were in the initial stages of their clinical audits. The Intern participation in clinical audits will be reviewed at 6 months and the end of the training year to assess if the CATS program has had a significant impact on intern participation in clinical audits. Table 3 Descriptive statistics of the interns performing clinical audits and comparison with the previous year’s performance. Interns performing clinical audits Group Total interns Involved in audits during internship Percent (%) Ex-Interns (2021–2022) 31 2 6 Current Interns (2022–2023) before CATS 30 0 0 Current Interns (2022–2023) 3 weeks post CATS 30 8 27 The post-test knowledge score following the initial lecture was significantly higher than the pre-test score. The attitude of interns towards clinical audit and quality improvement were neutral and remained unchanged following the CATS initiative. Higher proportion of interns were actively involved in clinical audits following the CATS initiative. DISCUSSION A traditional didactic lecture method was chosen for the delivery of the module content to the learners for pragmatic reasons like time constraints and availability of pre-structured mandatory lecture sessions for interns. Although Osler believed that the lecture method of instruction should be abolished, allowing students more time to study, he also emphasized the role of a teacher in helping students to observe and reason.(William Osler 1913 ) while it may be argued that lecturing is a traditional method of teaching, that has been used for several decades, and is often seen as insufficient and unreasonable to teach using these traditional didactic methods, effecting effective lecturing is shown to stimulate learning. (Sahu & Lata 2010 ) A pre-test post-test analysis of knowledge gained by medical students following didactic lecture, due to time restriction and vast syllabus to be covered, found that there was significant improvement in the recipient knowledge following the lecture reflecting a good improvement in cognitive structure (Padmanabha Thiruganahalli et al. 2017 ) Nonetheless, the use of lectures in medical education is not without pitfalls. Therefore, the clinical audit lecture was developed targeting the Interns with the content tailored to an appropriate level of detail accounting for the short attention span of the learners. The lecture was delivered by two lecturers using a short PowerPoint presentation, linking images and texts effectively to ensure that the learners and not the speakers were the primary educational focus (Lowe & Borkan 2021 ) The author, who also delivered the lecture for the intents used a narrative example of his own audit experience to engage the audience. Students and lecturers have highlighted the importance of narrative learning, which is often seen as a hook to engage the audience and as a memory aid. (Easton 2016 ) The interns already had scheduled weekly teachings on Thursdays that lasted for one hour so it was pragmatic to schedule the lecture for one of those teaching sessions that were available already. And lectures can often be a pragmatic way of introducing junior doctors to Clinical Audits and quality improvement given the time constraints and the extent of knowledge that needs to be transferred to the junior doctors. Following up the lecture on clinical audit with a structured training and support program for the interns significantly increased intern participation in Clinical Audits and quality improvement but their attitude remained neutral. Training initiatives like the CATS program communicates the organization's welcoming attitude towards junior doctors involvement in quality improvement. Such ingrained attitudes and organizational cultures are likely to promote engagement in quality improvement initiatives by making them feel more comfortable and confident in doing Clinical Audits (Anvik et al. 2008 ) Furthermore, it is essential for junior doctors to be supported in their initiatives on quality improvement because the people that they work with, can influence their practice style and the degree to which they engage in quality improvement (Chung et al. 2003 ) The near-peer mentors were one or two years senior to the interns. The informal interactions in a non-judgemental environment can promote cognitive and social congruence amongst mentors and the interns. (Loda et al. 2020 ) Thus, the mentors who were carefully selected and who had completed a full cycle of audit themselves and had actively involved in quality improvement played a vital role in our CATS program in improving intern participation in Clinical Audits. However, it must also be noted that interviews with foundation doctors in Scotland found that the mentor characteristics can either help or hinder their participation in quality improvement. (Kendall et al. 2005 ) Hence, careful selection of the trainers or mentors for the CATS program was crucial in its success. Researchers from Australia found that junior doctors valued supervisory support of two kinds assistance from senior clinicians who are experts in areas where the trainee trainees need help, and trust to act independently without feeling abandoned, does that's supervision should be both structured and dynamic, which would reassure the junior doctors that they are in the place of safe learning with adequate and flexible support. (Iedema et al. 2010 ) In addition, the potential to improve communication skills through collaborative work with non-physician members of the audit team could explain another reason for increased participation in quality improvement initiatives. A case study in the USA found that a physician working jointly with a non-physician member of the audit team increased the success of the audit projects and the residents involvement enhanced when they were given concrete tasks and were asked to forge community connections. (Harper et al. 2000 ) However, poor communication skills of interns may impede their participation in quality improvement. And it must be emphasized that effective and efficient communication is crucial in healthcare practice and development. (Vermeir et al. 2015 ) Most junior doctors find the experiential format of learning to work well for them which has been tested in research models in Canada for teaching quality improvement. (Sockalingam et al. 2010 ) There are also several examples from the USA, suggesting that practical projects can improve junior doctors knowledge and skills in Clinical Audits and quality improvement, (O’Connor et al. 2010 ; Vinci et al. 2010 ) In one study, residents who were involved in Clinical Audits and quality improvement reported improved knowledge and self-efficacy regarding quality improvement initiatives and motivation to make improvements to clinical practice. (Canal et al. 2007 ) Improved intern participation in quality improvement initiatives can improve patient outcomes. Only 2 interns had completed a clinical audit project at the end of their training year in the previous year; however, following the CATS program, 8 - intern were already involved in a clinical audit and quality improvement initiative within the first 3-months of their internship. As interns rotate through less busier teams over the course of the year, more interns might get involved in Clinical Audits. These quality improvement initiatives can certainly have an impact on the higher levels of Patrick's outcomes. Because quality improvement initiatives developed by junior doctors as part of their training can improve patient care and outcomes. (Laiteerapong et al. 2011 ) Most clinical audit projects result in suggestions for change, which when implemented can sustain improved patient care beyond residents project period (Tomolo et al. 2009 ) Regardless of the motivation of the junior doctors to participate in quality improvement, the crucial factor that influences the degree to which they are involved in quality improvement is the amount of work demands placed on junior doctors in their physical work environments. As in the UK, Europe and North America, there has been a reduction in the maximum number of hours per week that junior doctors can work in Ireland. While most studies have suggested that this does not impact negatively on the patient outcomes, it is believed that this leaves less time for intern training, education and development in areas such as Quality Improvement (Chaponda et al. 2009 ; McIntyre et al. 2010 ) Interns rotating through busy teams may not find the opportunity to explore the options of doing an audit or to discuss any proposals with more senior members of the team. Thus providing informal support through a CATS program is a way to encourage exploration of any audit ideas of junior doctors in a more friendly and relaxed environment. Personal factors like professional examinations, financial demands, or health issues can also influence the level of intern involvement in Clinical Audits and quality improvement. Nearly all junior doctors have to study and revise for high stake postgraduate examinations while doing busy hospital jobs, with nights and weekend calls, other financial demands or health issues can also limit the amount of time that junior doctors can dedicate towards performing Clinical Audits. (Black & Guthrie 1991 ) Thus incentivizing involvement in Clinical Audits and quality improvement can encourage junior doctors to prioritize quality improvement initiatives. (Stewart et al. 2016 ) Finally there is a need for protected time for junior doctors to be involved in Clinical Audits. As part of an emergency audit Initiative (EAI) Program at Redcliffe hospital, Australia in 2018 16 interns (59%) were paired with a staff specialist audit mentor, and completed a clinical audit during the 10 week ED term. The interns had 4-hours of paid protected off-the-floor time during their ED term to review the medical records for their audit within the department. The interns reported that they had adequate time (94%) and resources (81%) to conduct the audit and the EAI initiative had a modest impact on clinical practice. (Windish et al. 2021 ) The lack of protected audit time for interns could explain the comparatively lower levels of intern participation (33%) in our study. Future CATS programs should consider paid protected off-the-floor time for junior doctors involved in Clinical Audits and quality improvement. Thus, providing junior doctors with an opportunity to be involved in Clinical Audits early on in their careers will not only make a difference to their ongoing professional development, but it will also impact the degree to which they prioritize quality improvement in future. (Health foundation 2011 ) Strengths and limitations The study had good sample representation with questionnaires comprehensively assessing the knowledge, attitudes, and behaviours of interns and a plan to follow up on interns’ involvement in Clinical Audits at the end of the training year. Despite the varying attendance at the intern teaching, more than half of the interns (n = 16) were represented in the pre-test post-test analysis. The questionnaire was designed to assess interns’ knowledge about Clinical Audits and their attitude towards performing Clinical Audits and their involvement in quality improvement initiatives. All interns who attended the teaching session answered the questionnaire even though the participation was voluntary. The analysis using paired samples provided strong evidence that the lecture on clinical audit significantly increased the knowledge scores of interns about Clinical Audits. Although the sample size was appropriate, a convenient voluntary sampling was used due to pragmatic reasons and time constraints, which limits the generalization of the results. Not all interns who attended the lecture participated in the CATS program due to personal reasons and work pressures. True or false questions used in the knowledge questionnaire was appropriate to assess theoretical knowledge recall, but the binary answers increased the probability of chance in the results. Even though intern involvement in Clinical Audits was assessed too early at three weeks following the initiation of the CATS program, follow up at six months and at the end of the training year would provide additional information. Finally, a qualitative approach would help gain valuable insights into interns’ attitude and behaviour in performing Clinical Audits and quality improvement initiatives rather than testing assumptions. Implications for practice A lecture on clinical audit and quality improvement for the interns during the beginning of their internship can help them refresh their knowledge on Clinical Audits and orient them to the local policies and procedures on Clinical Audits and quality improvement. Although junior doctors express high motivation to participate in Clinical Audits and quality improvement their actual participation and involvement in Clinical Audits is limited. However, a Structured clinical audit training and support program can help improve participation of junior doctors in Clinical Audits and quality improvement early on in their careers. Future training and support programs for junior doctors and Clinical Audits should include paid protected off-the-floor time for audit related work and quality improvement initiatives. Participation of junior doctors in Clinical Audits early on in the carriers will not only improve their professional practice, but will also influence their involvement in quality improvement in future. CONCLUSION Audit related teaching to junior doctors at the beginning of their career as hospital doctors can help recall audit related knowledge and learn local quality improvement policies. Although junior doctors want to be involved in quality improvement initiatives, their attitude towards clinical audits remain neutral due to lack of time, training and support. A structured training and support program for junior doctors promotes their participation in quality improvement initiatives and improves service outcome measures. DECLARATIONS ACKNOWLEDGEMENTS None DECLARATION OF INTEREST STATEMENT Ethics approval and consent to participate Ethical approval was granted from the Swansea University Ethics Sub-Committee (SUMS RESC 2022 - 0073) Written consent was provided by participants before taking part in this study. Consent for publication Participants in this study gave informed written consent to publication of their anonymised data. Competing interests The authors declare that they have no competing interests. FUNDING There was no funding required for this study. JA completed this study under the supervision of ADS and EC as part of his Masters in Medical Education at Swansea University. REFERENCES Agents for change. 2022. Jr Dr agents Chang blog [Internet]. https://agentsforchange.tumblr.com/ Anvik T, Grimstad H, Baerheim A, Bernt Fasmer O, Gude T, Hjortdahl P, Holen A, Risberg T, Vaglum P. 2008. 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Dubl J Med Sci 1872-1920. 136(5):313–27. Windish R, Morel D, Forristal CE. 2021. Experience with a Clinical Audit Requirement for Interns in the Emergency Department. J Med Educ Curric Dev. 8:23821205211016508. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3843380","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":265747581,"identity":"207c26e3-1c2d-4299-a8e1-5ba4328861f0","order_by":0,"name":"Joseph Anderson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYBACxoYEBsaP/2xAzMYDRGthlmBLAzOJ08LAkMDAwMN2GMwkTgtze/KzBxI85+3Wth8G2lJjE03YYT3PzA0KJG4nbzuTCNRyLC23gaCWGQlmEhIGt5PNDgC1MDYcJkZL+jcJnoRzyWbnHxKtJcdMgufAATuzG0Tb0vOm3FiyITnB7AbQlgRi/GLYnr7t4ccGO3uz8+kPH3yosSFCSwMDG4hOBKtMIKQcBOQZIFrsiVE8CkbBKBgFIxQAAFBUSHWzhWjaAAAAAElFTkSuQmCC","orcid":"","institution":"RCSI Group of Hospitals, Dublin, Ireland","correspondingAuthor":true,"prefix":"","firstName":"Joseph","middleName":"","lastName":"Anderson","suffix":""},{"id":265747582,"identity":"30e607b9-51ad-4b29-a36f-c793a977c4f1","order_by":1,"name":"Eleanor Carton","email":"","orcid":"","institution":"Our Lady of Lourdes Hospital, Drogheda, Co.Louth, Ireland","correspondingAuthor":false,"prefix":"","firstName":"Eleanor","middleName":"","lastName":"Carton","suffix":""},{"id":265747583,"identity":"4c302e41-2583-494a-8513-ed41f43fc724","order_by":2,"name":"Ana Sergio Da Silva","email":"","orcid":"","institution":"Swansea University, Swansea, UK","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Sergio Da","lastName":"Silva","suffix":""}],"badges":[],"createdAt":"2024-01-07 19:22:40","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3843380/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3843380/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49384323,"identity":"1274effa-2335-4d3e-bad3-1605fee30276","added_by":"auto","created_at":"2024-01-09 19:45:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":22485,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of the pre-test and post test scores of interns’ knowledge about clinical audits\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3843380/v1/19c7c8c94994fe76a91583e1.png"},{"id":49386173,"identity":"05982b41-58a2-4ea9-b16a-da2d269e6c04","added_by":"auto","created_at":"2024-01-09 19:53:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322511,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3843380/v1/34d5b980-21be-4949-8d31-a0e3e333d240.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eImpact of a structured training and support program on junior doctors’ participation in clinical audits\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eClinical audit is the measurement of clinical outcomes or process against a well-defined standards set on the principles of evidence based medicine with an aim to improve the quality of patient care. (Esposito \u0026amp; Dal Canton \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) Clinical Audits which are quality improvement measures, and one of the Seven Pillars of clinical governance are vital aspects of clinical governance and continual service improvement in medicine (Limb et al. \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) Clinical Audits not only improve patient outcomes, but also promote awareness about the clinical standards amongst practicing clinicians. (Thomson O\u0026rsquo;Brien et al. \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) The Irish Medical Council in its Guide to Professional Conduct emphasizes the importance of Clinical Audits in evidence based medicine and the need for medical practitioners, including junior doctors to participate in clinical continuing medical education.(IMC \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2009\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIt is widely believed that newly qualified junior doctors may be able to identify and improve clinical practices which more experienced doctors often take for granted (Gaiser \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) There is an increasing focus on junior doctors potential to improve healthcare outcomes and empowering them as agents for change. (Agents for change \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) Newly qualified doctors are often able to recognize gaps in service provision, but soon they adapt to fit within the status quo culture. Therefore, the initial period after graduation is vital in making junior doctors to become champions of change before they become fully embedded into the status quo. (Holland et al. \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAlthough the junior doctors views on clinical governance differ, widely. Intense support the principle of audit and are keen to participate in Clinical Audits. (Nettleton \u0026amp; Ireland \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) Every year in Ireland more than 1200 medical graduates make transition from being a medical student to being an intern predominantly in hospital settings. Despite the large number of medical graduates who start their career as interns only a few interns are involved in Clinical Audits and quality improvement due to the lack of audit related teaching and a structured program to guide interns through the audit process (Greenwood et al. \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e1997\u003c/span\u003e) Nonetheless, junior doctors can be trained and supported in quality improvement skills, which can result in real changes in the quality of patient care and outcomes.(Diaz et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eThe CATS program\u003c/h2\u003e \u003cp\u003e The clinical audit Training and Support (CATS) Program is an initiative to educate interns and promote their participation in Clinical Audits and quality improvement through the implementation of a learner centred curriculum that values self-directed, experiential and situated learning. The intended learning outcomes were identified following the Bigg\u0026rsquo;s principle of constructive alignment to support learning and teaching. (Loughlin et al. \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)The teaching and learning activities and assessment methods were then developed in alignment to the intended learning outcomes to help learners meet their learning outcomes. (John Biggs \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2014\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAs the conduct of clinical audit can be seen as an Entrustable professional activity (EPA) with increasing levels of entrustment and decreasing levels of supervision(Jarrett et al. \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) the interns were required to attend a one hour lecture initially on Clinical Audits following which they were given an opportunity to participate voluntarily in the CATS program and those who opted to participate in the cats program, were given time slots for workshops in small groups to identify their audit topics. And then they were linked with mentors who look who supervised 3\u0026ndash;4 interns. The interns had the flexibility of meeting with their mentors at their preferred times to discuss their audit ideas and further steps in an informal and relaxed environment. As part of the assessment, the intense were to answer true or false questions. They were also assessed based on their audit proposal, audit analysis and audit presentation submissions with a word limit of 250 words each.\u003c/p\u003e \u003cp\u003eThe trainers or the mentors were recreated on a voluntary basis with the requirement to have completed a clinical audit project themselves. The mentors guided the interns in the initial audit proposal and data collection and analysis processes with decreasing levels of supervision. The CATS program was to run over a period of 3\u0026ndash;6 months, during which time the interns enrolled in the program were expected to have successfully completed one PDSA cycle of clinical audit. The program was run under the supervision of the regional intern coordinator and the local Clinical audit coordinator. The program was to be continued in the forthcoming years following program evaluation and feedback from the interns and the trainers.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResearch aim\u003c/h2\u003e \u003cp\u003eTo assess the effectiveness of a Clinical Audit Training and Support (CATS) program in improving audit related knowledge, attitude, and participation in Interns. The primary research question was if the structured CATS program was superior in promoting intern attitude and participation in clinical audits compared to previous year Interns who did not have audit related teaching. The secondary research question was if participation in the clinical audit lecture as part of the CATS program improved retention of audit related knowledge at 3\u0026ndash;4 weeks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eA non-randomized quasi experimental pre-test post-test study was designed to assess the effect of the CATS program in improving the knowledge, attitude and behaviour of the interns towards clinical audits and quality improvement. This was a survey study using questionnaire prior to the initial lecture and 3 weeks later. The questionnaire included True or False questions and rating questions and was delivered in person at the Intern teaching to be completed using pen and paper.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe participants were new medical graduates who started as Intern doctors at the proposed study site in July 2022. About 20\u0026ndash;25 participants, in the age group 24\u0026ndash;34 years, with an equal proportion of males to females were proposed.\u003c/p\u003e \u003cp\u003eInclusion criteria\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParticipant should be an Intern doctor at the study site\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParticipant should attend the mandatory Intern teaching\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Participant should be able to provide informed consent\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParticipant should be able to answer questionnaires using pen/paper\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003cp\u003eExclusion criteria\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMore than 2 years\u0026rsquo; experience working as a doctor\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMore than 2 clinical audits performed in previous employment or medical school\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eIntended benefits of participation\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAll participants will benefit from a one-hour lecture on Clinical audit.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants willing to participate in clinical audits will have an opportunity to perform a clinical audit through the non-mandatory CATS program.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants who complete a clinical audit will be encouraged to present their audits at the regional Clinical audit day and receive a certificate of participation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eParticipants who complete an audit will gain valuable experience for professional growth and a certificate to support career progression.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImproved organizational performance and patient outcomes are the indirect outcomes of the research project assuming improved Intern participation in clinical audits\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eSampling and sample size\u003c/h2\u003e \u003cp\u003eA voluntary convenient sampling was used as the CATS program was a non-mandatory training initiative for the interns. 30 interns started internship at the study site on July 2022. Accounting for Interns who are on call, on leave or do not attend intern teaching there usually 20\u0026ndash;25 interns who attend the Intern teaching on Thursdays. Therefore, a convenient sample size of 20\u0026ndash;25 was chosen for data collection. However, there was a 20% sample attrition proposed due to non-availability of the same subjects at the pre-test and post-test sessions. Hence a final sample size of 15\u0026ndash;16 was proposed for the test re-test analysis.\u003c/p\u003e \u003cp\u003eThe intern doctors had mandatory weekly teachings on Thursdays. The participants were explained about the study, and were given opportunity to ask questions and were recruited to the lecture and CATS programme conditions. As the Audit lecture was delivered during one of the Intern teaching slots, the Intern doctors on duty were expected to be at the intern teaching (Mandatory). However, participation in the CATS programme was voluntary.\u003c/p\u003e \u003cp\u003eSelection of participants were not restricted; all Interns at the Intern teaching were provided with the Participant information sheet. The Consent process, Data protection policy and the research aims were discussed, and questions were clarified. Interns willing to participate in the CATS program were expected to provide their phone number. Following the lecture interns who provided their phone number were contacted and linked to their mentors as outlined in the CATS curriculum via WhatsApp.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe interns were provided with a two-sided data collection tool at the initial teaching session. On one side it contained the consent form including participant name and phone number. On the flip side there was a questionnaire that had 3 main sections:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe knowledge section of the questionnaire to provide a raw score out of 10 which reflected the audit knowledge of the interns.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe beliefs section of the questionnaire with reverse scoring for questions 2,3 and 5 to assess the attitude of Interns towards clinical audits.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026gt;\u0026thinsp;15 \u0026ndash; Positive attitude\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10 \u0026ndash; Negative attitude\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe experience section of the questionnaire to quantify the number of Interns involved in the clinical audits.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eAt the teaching session the interns were provided with the PIS first and then they were requested to sign the consent to participate in the research with their name subscribed. Then the Interns were given 10 mins to complete the questionnaire. After that the lecture was delivered by the lead researcher and the local clinical audit co-ordinator.\u003c/p\u003e \u003cp\u003e At the end of the lecture interns were advised to complete the willingness to participate in clinical audit section and provide phone number. Thereafter, the interns who were willing to participate in the CATS program were linked to their respective tutors and had training and support as outlined in the CATS curriculum. 2\u0026ndash;4 weeks after the initial lecture all interns regardless of whether they participated in clinical audits (CATS) or not, were requested to complete the questionnaire once again following scheduled Intern teaching on a Thursday.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe survey questionnaire were reviewed for usability, inclusion, and exclusion criteria. Descriptive statistics was to include the number of interns, central tendencies of the knowledge score and attitude score. Inferential statistics was to include Student\u0026rsquo;s t-test of the pre- and post-audit knowledge, attitude, and experience. Data was to be analysed using SPSS 24.0 software.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere were 31 and 30 Interns who rotated through various medical and surgival job whike Following ethical approval, the initial lecture on audit was delivered on 08.09.22 and the post-test was 2-weeks later. 21 (70%) Interns were present at the initial audit and all of them participated voluntarily in answering the questionnaire. Later, 20 (67%) interns were present for the post-test and all of them answered the questionnaire. For paired t-test analysis 16 Interns (53%) who participated in the pre-test and post-test were used.\u003c/p\u003e\n\u003cp\u003eThe knowledge test score (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e) of the 16 participants (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD); at baseline, 2-weeks post lecture and paired differences were 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0, 7.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9, and 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8, respectively. Paired samples \u003cem\u003et\u003c/em\u003e test indicated that mean difference of paired observations of knowledge test score between baseline and 2-weeks post lecture was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The post test scores were significantly higher and there were no scores below 5 in the post test. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDescriptive statistics of pre-test and post-test scores of interns\u0026rsquo; knowledge about clinical audits\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eAudit knowledge score\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMinimum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaximum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStd. Deviation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePre-test score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.2500\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00000\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePost - test score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.3750\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.02470\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eValid N (listwise)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe post test scores were significantly higher and there were no scores below 5 in the post test. (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Most interns improved on questions related to the steps involved in the audit cycle and the non-requirement of ethical approval for clinical audits.\u003c/p\u003e\n\u003cp\u003eThe Attitude score (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) of the 16 participants (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD); at baseline, 2-weeks post lecture and paired differences were 16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0, 16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8, and 0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2, respectively. Paired samples \u003cem\u003et\u003c/em\u003e test indicated that mean difference of paired observations of attitude score between baseline and 2-weeks post lecture was not statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.18). Though All interns agreed that they wanted to do an audits, the overall attitude towards performing audits was neutral.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDescriptive statistics of the 5-point Likert scale assessing the attitude of interns towards clinical audits.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eAttitude towards clinical audits\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAttitude towards audits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMinimum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMaximum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStd. Deviation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eI want to do audit\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.4375\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.62915\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAudits are doable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.6250\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.88506\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eI will have time for audits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.2500\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.06458\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eI will be supported in audits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3750\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.02470\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAudit is my responsibility also\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.1875\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.91059\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eValid N (listwise)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eWith regards to Interns quality improvement behaviours (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e), only 2 interns (6%) performed a clinical audit during their internship in 2021\u0026ndash;2022 at the study site. None of the current Interns (2022\u0026ndash;2023) were involved in any clinical audits prior to the CATS program. 3-weeks following the initial lecture and the CATS program 8 Interns (27%) were in the initial stages of their clinical audits. The Intern participation in clinical audits will be reviewed at 6 months and the end of the training year to assess if the CATS program has had a significant impact on intern participation in clinical audits.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDescriptive statistics of the interns performing clinical audits and comparison with the previous year\u0026rsquo;s performance.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInterns performing clinical audits\u003c/strong\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal interns\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eInvolved in audits during internship\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePercent (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEx-Interns (2021\u0026ndash;2022)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e31\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCurrent Interns (2022\u0026ndash;2023) before CATS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCurrent Interns (2022\u0026ndash;2023) 3 weeks post CATS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eThe post-test knowledge score following the initial lecture was significantly higher than the pre-test score. The attitude of interns towards clinical audit and quality improvement were neutral and remained unchanged following the CATS initiative. Higher proportion of interns were actively involved in clinical audits following the CATS initiative.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eA traditional didactic lecture method was chosen for the delivery of the module content to the learners for pragmatic reasons like time constraints and availability of pre-structured mandatory lecture sessions for interns. Although Osler believed that the lecture method of instruction should be abolished, allowing students more time to study, he also emphasized the role of a teacher in helping students to observe and reason.(William Osler \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e1913\u003c/span\u003e) while it may be argued that lecturing is a traditional method of teaching, that has been used for several decades, and is often seen as insufficient and unreasonable to teach using these traditional didactic methods, effecting effective lecturing is shown to stimulate learning. (Sahu \u0026amp; Lata \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA pre-test post-test analysis of knowledge gained by medical students following didactic lecture, due to time restriction and vast syllabus to be covered, found that there was significant improvement in the recipient knowledge following the lecture reflecting a good improvement in cognitive structure (Padmanabha Thiruganahalli et al. \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) Nonetheless, the use of lectures in medical education is not without pitfalls. Therefore, the clinical audit lecture was developed targeting the Interns with the content tailored to an appropriate level of detail accounting for the short attention span of the learners. The lecture was delivered by two lecturers using a short PowerPoint presentation, linking images and texts effectively to ensure that the learners and not the speakers were the primary educational focus (Lowe \u0026amp; Borkan \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe author, who also delivered the lecture for the intents used a narrative example of his own audit experience to engage the audience. Students and lecturers have highlighted the importance of narrative learning, which is often seen as a hook to engage the audience and as a memory aid. (Easton \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) The interns already had scheduled weekly teachings on Thursdays that lasted for one hour so it was pragmatic to schedule the lecture for one of those teaching sessions that were available already. And lectures can often be a pragmatic way of introducing junior doctors to Clinical Audits and quality improvement given the time constraints and the extent of knowledge that needs to be transferred to the junior doctors.\u003c/p\u003e \u003cp\u003e Following up the lecture on clinical audit with a structured training and support program for the interns significantly increased intern participation in Clinical Audits and quality improvement but their attitude remained neutral. Training initiatives like the CATS program communicates the organization's welcoming attitude towards junior doctors involvement in quality improvement. Such ingrained attitudes and organizational cultures are likely to promote engagement in quality improvement initiatives by making them feel more comfortable and confident in doing Clinical Audits (Anvik et al. \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2008\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFurthermore, it is essential for junior doctors to be supported in their initiatives on quality improvement because the people that they work with, can influence their practice style and the degree to which they engage in quality improvement (Chung et al. \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2003\u003c/span\u003e) The near-peer mentors were one or two years senior to the interns. The informal interactions in a non-judgemental environment can promote cognitive and social congruence amongst mentors and the interns. (Loda et al. \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) Thus, the mentors who were carefully selected and who had completed a full cycle of audit themselves and had actively involved in quality improvement played a vital role in our CATS program in improving intern participation in Clinical Audits.\u003c/p\u003e \u003cp\u003eHowever, it must also be noted that interviews with foundation doctors in Scotland found that the mentor characteristics can either help or hinder their participation in quality improvement. (Kendall et al. \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) Hence, careful selection of the trainers or mentors for the CATS program was crucial in its success. Researchers from Australia found that junior doctors valued supervisory support of two kinds assistance from senior clinicians who are experts in areas where the trainee trainees need help, and trust to act independently without feeling abandoned, does that's supervision should be both structured and dynamic, which would reassure the junior doctors that they are in the place of safe learning with adequate and flexible support. (Iedema et al. \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2010\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn addition, the potential to improve communication skills through collaborative work with non-physician members of the audit team could explain another reason for increased participation in quality improvement initiatives. A case study in the USA found that a physician working jointly with a non-physician member of the audit team increased the success of the audit projects and the residents involvement enhanced when they were given concrete tasks and were asked to forge community connections. (Harper et al. \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2000\u003c/span\u003e) However, poor communication skills of interns may impede their participation in quality improvement. And it must be emphasized that effective and efficient communication is crucial in healthcare practice and development. (Vermeir et al. \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eMost junior doctors find the experiential format of learning to work well for them which has been tested in research models in Canada for teaching quality improvement. (Sockalingam et al. \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) There are also several examples from the USA, suggesting that practical projects can improve junior doctors knowledge and skills in Clinical Audits and quality improvement, (O\u0026rsquo;Connor et al. \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Vinci et al. \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) In one study, residents who were involved in Clinical Audits and quality improvement reported improved knowledge and self-efficacy regarding quality improvement initiatives and motivation to make improvements to clinical practice. (Canal et al. \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2007\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eImproved intern participation in quality improvement initiatives can improve patient outcomes. Only 2 interns had completed a clinical audit project at the end of their training year in the previous year; however, following the CATS program, 8 - intern were already involved in a clinical audit and quality improvement initiative within the first 3-months of their internship. As interns rotate through less busier teams over the course of the year, more interns might get involved in Clinical Audits. These quality improvement initiatives can certainly have an impact on the higher levels of Patrick's outcomes. Because quality improvement initiatives developed by junior doctors as part of their training can improve patient care and outcomes. (Laiteerapong et al. \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) Most clinical audit projects result in suggestions for change, which when implemented can sustain improved patient care beyond residents project period (Tomolo et al. \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2009\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRegardless of the motivation of the junior doctors to participate in quality improvement, the crucial factor that influences the degree to which they are involved in quality improvement is the amount of work demands placed on junior doctors in their physical work environments. As in the UK, Europe and North America, there has been a reduction in the maximum number of hours per week that junior doctors can work in Ireland. While most studies have suggested that this does not impact negatively on the patient outcomes, it is believed that this leaves less time for intern training, education and development in areas such as Quality Improvement (Chaponda et al. \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2009\u003c/span\u003e; McIntyre et al. \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) Interns rotating through busy teams may not find the opportunity to explore the options of doing an audit or to discuss any proposals with more senior members of the team. Thus providing informal support through a CATS program is a way to encourage exploration of any audit ideas of junior doctors in a more friendly and relaxed environment.\u003c/p\u003e \u003cp\u003ePersonal factors like professional examinations, financial demands, or health issues can also influence the level of intern involvement in Clinical Audits and quality improvement. Nearly all junior doctors have to study and revise for high stake postgraduate examinations while doing busy hospital jobs, with nights and weekend calls, other financial demands or health issues can also limit the amount of time that junior doctors can dedicate towards performing Clinical Audits. (Black \u0026amp; Guthrie \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1991\u003c/span\u003e) Thus incentivizing involvement in Clinical Audits and quality improvement can encourage junior doctors to prioritize quality improvement initiatives. (Stewart et al. \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFinally there is a need for protected time for junior doctors to be involved in Clinical Audits. As part of an emergency audit Initiative (EAI) Program at Redcliffe hospital, Australia in 2018 16 interns (59%) were paired with a staff specialist audit mentor, and completed a clinical audit during the 10 week ED term. The interns had 4-hours of paid protected off-the-floor time during their ED term to review the medical records for their audit within the department. The interns reported that they had adequate time (94%) and resources (81%) to conduct the audit and the EAI initiative had a modest impact on clinical practice. (Windish et al. \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) The lack of protected audit time for interns could explain the comparatively lower levels of intern participation (33%) in our study. Future CATS programs should consider paid protected off-the-floor time for junior doctors involved in Clinical Audits and quality improvement.\u003c/p\u003e \u003cp\u003eThus, providing junior doctors with an opportunity to be involved in Clinical Audits early on in their careers will not only make a difference to their ongoing professional development, but it will also impact the degree to which they prioritize quality improvement in future. (Health foundation \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2011\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe study had good sample representation with questionnaires comprehensively assessing the knowledge, attitudes, and behaviours of interns and a plan to follow up on interns\u0026rsquo; involvement in Clinical Audits at the end of the training year. Despite the varying attendance at the intern teaching, more than half of the interns (n\u0026thinsp;=\u0026thinsp;16) were represented in the pre-test post-test analysis. The questionnaire was designed to assess interns\u0026rsquo; knowledge about Clinical Audits and their attitude towards performing Clinical Audits and their involvement in quality improvement initiatives. All interns who attended the teaching session answered the questionnaire even though the participation was voluntary. The analysis using paired samples provided strong evidence that the lecture on clinical audit significantly increased the knowledge scores of interns about Clinical Audits.\u003c/p\u003e \u003cp\u003eAlthough the sample size was appropriate, a convenient voluntary sampling was used due to pragmatic reasons and time constraints, which limits the generalization of the results. Not all interns who attended the lecture participated in the CATS program due to personal reasons and work pressures. True or false questions used in the knowledge questionnaire was appropriate to assess theoretical knowledge recall, but the binary answers increased the probability of chance in the results. Even though intern involvement in Clinical Audits was assessed too early at three weeks following the initiation of the CATS program, follow up at six months and at the end of the training year would provide additional information. Finally, a qualitative approach would help gain valuable insights into interns\u0026rsquo; attitude and behaviour in performing Clinical Audits and quality improvement initiatives rather than testing assumptions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cp\u003eA lecture on clinical audit and quality improvement for the interns during the beginning of their internship can help them refresh their knowledge on Clinical Audits and orient them to the local policies and procedures on Clinical Audits and quality improvement. Although junior doctors express high motivation to participate in Clinical Audits and quality improvement their actual participation and involvement in Clinical Audits is limited. However, a Structured clinical audit training and support program can help improve participation of junior doctors in Clinical Audits and quality improvement early on in their careers. Future training and support programs for junior doctors and Clinical Audits should include paid protected off-the-floor time for audit related work and quality improvement initiatives. Participation of junior doctors in Clinical Audits early on in the carriers will not only improve their professional practice, but will also influence their involvement in quality improvement in future.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAudit related teaching to junior doctors at the beginning of their career as hospital doctors can help recall audit related knowledge and learn local quality improvement policies. Although junior doctors want to be involved in quality improvement initiatives, their attitude towards clinical audits remain neutral due to lack of time, training and support. A structured training and support program for junior doctors promotes their participation in quality improvement initiatives and improves service outcome measures.\u003c/p\u003e"},{"header":"DECLARATIONS","content":"\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDECLARATION OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted from the Swansea University Ethics Sub-Committee (SUMS RESC 2022 - 0073) Written consent was provided by participants before taking part in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants in this study gave informed written consent to publication of their anonymised data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding required for this study. JA completed this study under the supervision of ADS and EC as part of his Masters in Medical Education at Swansea University.\u003c/p\u003e"},{"header":"REFERENCES","content":"\u003col\u003e\n\u003cli\u003eAgents for change. 2022. Jr Dr agents Chang blog [Internet]. https://agentsforchange.tumblr.com/\u003c/li\u003e\n\u003cli\u003eAnvik T, Grimstad H, Baerheim A, Bernt Fasmer O, Gude T, Hjortdahl P, Holen A, Risberg T, Vaglum P. 2008. Medical students\u0026rsquo; cognitive and affective attitudes towards learning and using communication skills--a nationwide cross-sectional study. Med Teach. 30(3):272\u0026ndash;279.\u003c/li\u003e\n\u003cli\u003eBlack D, Guthrie E. 1991. Preparing for postgraduate examinations. Br J Hosp Med. 46(3):170\u0026ndash;171.\u003c/li\u003e\n\u003cli\u003eCanal DF, Torbeck L, Djuricich AM. 2007. Practice-based learning and improvement: a curriculum in continuous quality improvement for surgery residents. 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BMC Med Educ [Internet]. 20(1):214. https://doi.org/10.1186/s12909-020-02129-x\u003c/li\u003e\n\u003cli\u003eLoughlin C, Lygo-Baker S, Lindberg-Sand \u0026Aring;. 2021. Reclaiming constructive alignment. Eur J High Educ [Internet]. 11(2):119\u0026ndash;136. https://doi.org/10.1080/21568235.2020.1816197\u003c/li\u003e\n\u003cli\u003eLowe RC, Borkan SC. 2021. Effective Medical Lecturing: Practice Becomes Theory: A Narrative Review. Med Sci Educ. 31(2):935\u0026ndash;943.\u003c/li\u003e\n\u003cli\u003eMcIntyre HF, Winfield S, Te H Sen, Crook D. 2010. Implementation of the European Working Time Directive in an NHS trust: impact on patient care and junior doctor welfare. Clin Med. 10(2):134\u0026ndash;137.\u003c/li\u003e\n\u003cli\u003eNettleton J, Ireland A. 2000. Junior doctors\u0026rsquo; views on clinical audit--has anything changed? Int J Heal care Qual Assur Inc Leadersh Heal Serv. 13(6\u0026ndash;7):245\u0026ndash;253.\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connor ES, Mahvi DM, Foley EF, Lund D, McDonald R. 2010. Developing a practice-based learning and improvement curriculum for an academic general surgery residency. J Am Coll Surg. 210(4):411\u0026ndash;417.\u003c/li\u003e\n\u003cli\u003ePadmanabha Thiruganahalli S, Gangadhar M, Vinaya M, Madhav K S. 2017. Evaluating the effectiveness of pre- and post-test model of learning in a medical school. Natl J Physiol Pharm Pharmacol. 7(9):947\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eSahu S, Lata I. 2010. Simulation in resuscitation teaching and training, an evidence based practice review. J Emerg Trauma Shock. 3(4):378\u0026ndash;384.\u003c/li\u003e\n\u003cli\u003eSockalingam S, Stergiopoulos V, Maggi J, Zaretsky A. 2010. Quality education: a pilot quality improvement curriculum for psychiatry residents. Med Teach. 32(5):e221-6.\u003c/li\u003e\n\u003cli\u003eStewart K, Bray B, Buckingham R. 2016. Improving quality of care through national clinical audit. Futur Hosp J. 3(3):203\u0026ndash;206.\u003c/li\u003e\n\u003cli\u003eThomson O\u0026rsquo;Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. 2000. Audit and feedback: effects on professional practice and health care outcomes. Cochrane database Syst Rev.(2):CD000259.\u003c/li\u003e\n\u003cli\u003eTomolo AM, Lawrence RH, Aron DC. 2009. A case study of translating ACGME practice-based learning and improvement requirements into reality: systems quality improvement projects as the key component to a comprehensive curriculum. Postgrad Med J. 85(1008):530\u0026ndash;537.\u003c/li\u003e\n\u003cli\u003eVermeir P, Vandijck D, Degroote S, Peleman R, Verhaeghe R, Mortier E, Hallaert G, Van Daele S, Buylaert W, Vogelaers D. 2015. Communication in healthcare: a narrative review of the literature and practical recommendations. Int J Clin Pract. 69(11):1257\u0026ndash;1267.\u003c/li\u003e\n\u003cli\u003eVinci LM, Oyler J, Johnson JK, Arora VM. 2010. Effect of a quality improvement curriculum on resident knowledge and skills in improvement. Qual Saf Health Care. 19(4):351\u0026ndash;354.\u003c/li\u003e\n\u003cli\u003eWilliam Osler. 1913. Examinations, examiners, and examinees. Dubl J Med Sci 1872-1920. 136(5):313\u0026ndash;27.\u003c/li\u003e\n\u003cli\u003eWindish R, Morel D, Forristal CE. 2021. Experience with a Clinical Audit Requirement for Interns in the Emergency Department. J Med Educ Curric Dev. 8:23821205211016508.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Our Lady of Lourdes Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Clinical Audit, Structured Training, CATS Program","lastPublishedDoi":"10.21203/rs.3.rs-3843380/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3843380/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite the large number of medical graduates who start their career as interns only a few interns are involved in Clinical Audits and quality improvement due to the lack of audit related teaching and a structured program to guide interns through the audit process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCATS Program Initiative\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe clinical audit Training and Support (CATS) Program is an initiative to educate interns and promote their participation in Clinical Audits and quality improvement through the implementation of a learner centred curriculum that values self-directed, experiential and situated learning. The CATS program was to run over a period of 3 months. During that time, the interns enrolled in the program were expected to have successfully completed one PDSA cycle of clinical audit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA non-randomized quasi experimental pre-test post-test study was designed to assess the effect of the CATS program in improving the knowledge, attitude and behaviour of the interns towards clinical audits and quality improvement. This was a survey study using questionnaire prior to the initial lecture and 3 weeks later. A voluntary convenient sampling was used as the CATS program was a non-mandatory training initiative for the interns.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were 31 and 30 Interns who rotated through various medical and surgical jobs. Following ethical approval, the initial lecture on the audit was delivered on 08.09.22, and the post-test was 2 weeks later. The post-test knowledge score following the initial lecture was significantly higher than the pre-test score. The attitude of interns towards clinical audit and quality improvement were neutral and remained unchanged following the CATS initiative. Higher proportion of interns were actively involved in clinical audits following the CATS initiative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAudit-related teaching to junior doctors at the beginning of their career as hospital doctors can help them recall audit-related knowledge and learn local quality improvement policies. Although junior doctors want to be involved in quality improvement initiatives, their attitude towards clinical audits remains neutral due to lack of time, training and support. A structured training and support program for junior doctors promotes their participation in quality improvement initiatives and improves service outcome measures.\u003c/p\u003e","manuscriptTitle":"Impact of a structured training and support program on junior doctors’ participation in clinical audits","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-09 19:45:50","doi":"10.21203/rs.3.rs-3843380/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"938d8cf9-cd68-413d-8877-64dbf5c90399","owner":[],"postedDate":"January 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":27995423,"name":"Hospital Medicine"}],"tags":[],"updatedAt":"2024-01-09T19:45:50+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-09 19:45:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3843380","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3843380","identity":"rs-3843380","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}