Protocol
Senior medical students as assistants in
medicine in COVID-19 crisis: a realist
evaluation protocol
Lynn V Monrouxe
,1 Peter Hockey,1,2 Priya Khanna,3 Christiane Klinner,1
4
Lise Mogensen, Deborah A O'Mara,3 Abbey Roach,2 Stephen Tobin,4
2
Jennifer Ann Davids
To cite: Monrouxe LV,
Hockey P, Khanna P, et al.
Senior medical students as
assistants in medicine in
COVID-19 crisis: a realist
evaluation protocol. BMJ Open
2021;11:e045822. doi:10.1136/
bmjopen-2020-045822
► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http://dx.doi.
org/10.1136/bmjopen-2020045822).
Received 15 October 2020
Accepted 21 July 2021
© Author(s) (or their
employer(s)) 2021. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.
1
Faculty of Medicine and Health,
The University of Sydney,
Sydney, New South Wales,
Australia
2
Research and Education
Network, Western Sydney Local
Health District, Sydney, New
South Wales, Australia
3
Sydney Medical School, The
University of Sydney, Sydney,
New South Wales, Australia
4
School of Medicine, Western
Sydney University, Penrith South,
New South Wales, Australia
Correspondence to
Dr Jennifer Ann Davids;
jennifer.davids@health.nsw.
gov.au
ABSTRACT
Introduction The assistant in medicine is a new and
paid role for final-year medical students that has been
established in New South Wales, Australia, as part of the
surge workforce management response to the COVID-19
pandemic. Eligibility requires the applicant to be a finalyear medical student in an Australian Medical Councilaccredited university and registered with the Australian
Health Practitioner Regulation Agency. While there are
roles with some similarities to the assistant in medicine
role, such as assistantships (the UK) and physician
assistants adopted internationally, this is completely new
in Australia. Little is known about the functionality and
success factors of this role within the health practitioner
landscape, particularly within the context of the COVID-19
pandemic. Given the complexity of this role, a realist
approach to evaluation has been undertaken as described
in this protocol, which sets out a study design spanning
from August 2020 to June 2021.
Methods and analysis The intention of conducting
a realist review is to identify the circumstances and
mechanisms that determine the outcomes of the assistant
in medicine intervention. We will start by developing an
initial programme theory to explore the potential function
of the assistant in medicine role through realist syntheses
of critically appraised summaries of existing literature
using relevant databases and journals. Other data sources
such as interviews and surveys with key stakeholders will
contribute to the refinements of the programme theory.
Using this method, we will develop a set of hypotheses
on how and why the Australian assistants in medicine
intervention might ‘work’ to achieve a variety of outcomes
based on examples of related international interventions.
These hypotheses will be tested against the qualitative
and quantitative evidence gathered from all relevant
stakeholders.
Ethics and dissemination Ethics approval for the larger
study was obtained from the Western Sydney Local Health
District (2020/ETH01745). The findings of this review
will provide useful information for hospital managers,
academics and policymakers, who can apply the findings
in their context when deciding how to implement and
support the introduction of assistants in medicine into the
health system. We will publish our findings in reports to
policymakers, peer-reviewed journals and international
conferences.
Strengths and limitations of this study
► A realist evaluation design is able to provide a
deeper level of understanding as to how an intervention in complex situation works by assessing the
interaction of the underlying causal factors through
an investigation of the context, mechanisms and
outcomes.
► The ongoing and iterative nature of the realist syntheses and evaluation allows for complex interpretation of the programme theory and the development
of middle-range theories.
► The survey will be sent to 55 assistant in medicine
participants at the end of the programme, which
may prove problematic in terms of data analysis.
INTRODUCTION
New South Wales (NSW) State Ministry of
Health, the largest health system in Australia,
reviewed its workforce capacity in anticipation of a COVID-19 surge. As a result, a new
assistant in medicine role has been created to
work within non-COVID-19 multidisciplinary
teams to provide extra medical assistance
should junior medical officers be redeployed.
These roles have been filled by final-year
medical students. These students volunteered
via their medical school, which reviewed their
progress and certified them as having appropriate knowledge and skills. The assistant in
medicine role is officially paid, workplace
employment, rather than a clinical placement. Despite students being able to express
an interest in a particular placement, this
role has been designed so that it aligns with
local health district service needs rather than
with the students’ potential career interests.
The role is part-time and based on a temporary contract extending to a maximum of 6
months at 32 hours per week, with variation
across different local health districts, which
equates to approximately 3–4 shifts per
week at the most. The assistants in medicine
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
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Open access
continued with their university medical course 1 day per
week to fulfil their curriculum requirements. Furthermore, some assistants in medicine received synchronous
and asynchronous educational sessions and engaged with
entrustable professional activities (a competency framework).1 This unique assistant in medicine initiative has
provided an opportunity to evaluate whether the clearly
defined expectations and intended outcomes desired by
the various stakeholders (including universities, local
health districts and the NSW State Ministry of Health) are
met. The results from the study will be disseminated to
these key stakeholders to inform future policy decisionmaking concerning the ongoing nature of the assistant
in medicine role and inform curriculum designers within
medical schools regarding final-year students’ preparedness for practice issues. We also anticipate a reciprocal
transferability of knowledge with other related initiatives
outlined below.
Relationships to other initiatives
There are a number of existing roles that relate to the
assistant in medicine scheme. These include the roles of
assistantships in medicine,2–6 introduced in the UK to ease
the transition of final-year medical students into their
junior doctor roles, and the physician assistant/physician
associate7–20 role, first introduced in the USA. Although
these roles differ from the assistant in medicine role, they
do offer significant insights into the implications of introducing new roles to fill the vacancy of clinical personnel
within the hospital system and considering new options
for the transition into practice for final-year medical
students. We outline these roles below.
Medical students’ assistantships
Assistantships in the UK are medical students who, via a
longitudinal full-time placement, are integrated into a
healthcare team for the last few months of their clinical
training to gain phased-in hands-on experience carrying
out the work of a newly qualified doctor under appropriate supervision.2–5 21 Thus, the timing of assistantships
is the same as the assistants in medicine. Similar to assistants in medicine, assistantships differ in length from 3
to 6 months, and they can be undertaken in the hospital
where students will eventually be appointed.5 6 However,
unlike assistants in medicine, some assistantships are
aligned with the exact role to which they are about to
transition.5 6 The purpose of this assistantship role is
to smooth the transition from being a student to being
a professional,22 hopefully easing their passage into a
professional role by gradually preparing them for the
responsibilities they will face as a junior doctor.2 23 24 This
purpose is only partly aligned with that of the assistants in
medicine, as their key purpose was to provide assistance
should junior medical officers be otherwise deployed (so
they are there to fill a service gap due to the pandemicrelated demands).
This assistantship role is not without its challenges. Some
students report struggling to participate effectively due
2
to a lack of clarity about the nature of their role. Consequently, students narrate becoming passive, preventing
open participation, active learning and the development
of professional identity as a junior doctor.2 This, it is
suggested, can compound student stress and clinical risk,
and hamper meaningful appraisal of their professional
development.2 24 As a result, the development of a sense
of belonging and feeling like a doctor (ie, their professional identity) may be delayed due to the lack of meaningful participation in professional activities.2
Students who report being supported narrated their
experiences in a markedly different manner to those who
did not. Indeed, this support eased students’ transition
into their professional role, feeling it to be ‘business as
usual’ due to their existing understanding of requirements and work practices for an F1 (Post Graduate Year
1(PGY1)).24 As Crossley and Vivekananda-Schmidt state,
‘the gap then between student and doctor is quite clear. It
is participation in healthcare delivery with a real purpose’.2
Indeed, responsibility and participation in professional
activities appear to be crucial for furnishing students with
confidence, resilience and proactive behaviours in professional practice and reinforcing aspects of personal development also delivered in the university curriculum.24 Key
aspects of the assistantship programme appear to be the
quality of supervision provided to students in this role3 25
and the extent to which they are accepted and mentored
into multidisciplinary teams.2
The unpaid assistantship differs from the assistant in
medicine role in that it is a full-time student role with
the main intention of gradually integrating students into
practice as paid employees, while the assistant in medicine is a part-time role that was intended to act as a fully
functioning team member. They are similar to each other
in that both roles are held by final-year medical students
at the end of their degree, and there is an element of
transition smoothing with both.
Physician assistant/associate
The role of physician assistant or physician associate was
introduced in the USA in 1965 and then developed internationally (eg, in countries such as Australia, Canada,
England, the Netherlands, Scotland, South Africa and
Taiwan). In Australia, this role was proposed to meet
the demand for medical services following a drive for a
healthier society through the introduction of Medicare;
however, it wasn’t implemented.18 Physician assistant/
associates are usually able to undertake routine technical
tasks and so relieve the load of the physician.26 However,
physician associates are less qualified than a physician
and unable to work independently.18
A number of impediments restricting the use of physician assistant/Associates have been identified including
legal issues, training programmes, lack of medical school
attendance and unclear role relationships.7 However,
it has been found that the physician assistant/associate
role can reduce pressure on struggling health systems
and successfully fill a much-needed gap in healthcare. In
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
BMJ Open: first published as 10.1136/bmjopen-2020-045822 on 6 September 2021. Downloaded from http://bmjopen.bmj.com/ on February 25, 2022 by guest. Protected by copyright.
Open access
addition, where these roles are deployed, patient feedback
is largely favourable, and there is reportedly an increase
of team flexibility, continuity of care and smooth patient
flow.9 14 Physician assistant/associates offer the capacity
to fill roles currently filled by medical staff, thus saving
on resources,16 and provide opportunities for doctors to
spend time on more complex patients and to attend to
patients in clinic and theatre settings.14 15 Physician assistant/associates are found to be valued for their generalism, health background, confidence in differential
diagnoses and communication. Furthermore, the presence of physician assistant/associates can enhance postgraduate medical education through filling in for junior
doctors and releasing them from duties.12 13 However,
doctors are concerned about the reduction of medical
education opportunities for junior doctors caused by this
role as attention is diverted to the training of new physician assistant/associates, which is not generally supported
in practice.
In fact, this role has caused great disquiet among junior
doctors. For example, in the UK, junior doctors voted
to ‘actively oppose’ the medical associate professionals
(MAPs) to being treated equally to them in relation to
medical staffing. MAPs include physician associates and
advanced critical care practitioners.11 Issues associated
with the role are based around regulation, registration,
autonomy and a lack of understanding or knowledge
about the role.9 15 17 19 20 Ignorance about the physician
assistant/associate role can cause problems for physician
assistant/associates with regard to identity formation
and identity dissonance,8 and there are issues around
managing the expectations of the role by both those
training to be physician assistant/associates and healthcare staff.10 Lastly, lack of options for physician assistant/
associates can impact career advancement, and there is a
propensity for burnout.19
While both the physician assistant/associate and assistant in medicine roles are paid positions and both filling
a service gap, there are differences between the roles. For
example, the physician assistant/associate is full time and
does not include integrated study time, and the role will
not lead to the position of a physician or open a career
pathway to further progression or result in autonomy of
practice. Second, the former have graduated from their
medical programme, whereas the assistant in medicine
has not graduated with some assistants in medicine having
more curriculum and assessment to undertake. Furthermore, physician assistant/associates are interdependent,
semiautonomous clinicians practising in partnership with
physicians, whereas assistants in medicine work under
clinicians’ supervision. The tasks that each assistant in
medicine student is allowed to do are expected to vary
according to the hospital and team they are allocated to.
Research aims
The NSW Health-sponsored Assistant in Medicine Initiative provides a unique opportunity to assess the extent to
which this new workforce model works to achieve different
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
outcomes for the stakeholders involved in the initiative
(across both educational and workplace settings). This
study seeks to evaluate the Assistant in Medicine Initiative by unpacking the nuances using realist synthesis
and realist evaluation27–29 in an integrated, coordinated
and collaborative approach. Given the diverse range of
expected outcomes by different stakeholders (namely,
clinical schools, local health districts, the Ministry
of Health, the assistants in medicine and their team
workers), the protocol could be applied to other sites
where this role has been implemented.
RESEARCH QUESTIONS (RQS)
Our study has two overarching RQs:
RQ1: To what extent does the assistant in medicine
intervention meet the expectations (outcomes) of stakeholders, in terms of what works, for whom, how and in
what circumstances?
RQ2: What conclusions can we draw from our findings
that will benefit the future development and implementation of an assistant in medicine–type programme as an
ongoing venture for final-year medical students?
METHODS
Theory-driven approaches such as realist synthesis and
realist evaluation will be used to address our RQs. Based
on the Realist And Meta-narrative Evidence Syntheses:
Evolving Standards (RAMESES) protocol,30 the evaluation is based on three phases, namely, phase 1, realist
synthesis; phase 2, realist evaluation; and phase 3, analysis.
Underpinned by realist philosophy of science, the
methods’ strength lies in providing a generative understanding of causality. Thus, for any specific outcome (O),
there are underlying mechanisms (M) that cause that
outcome in a given context (C). These underlying mechanisms are not obvious and are subject to the interaction
of combining factors that may alter depending on the
opportunities that are embedded in specific context(s).
An exploration of these mechanisms can reveal the
drivers behind (un)intended outcomes and explain the
circumstances in which these mechanisms are activated.
Below, we outline the phases of our study.
Phase 1: a realist synthesis
Realist synthesis comprises a broad-based review of all
literature available (including electronic articles, books
and grey literature) regarding similar initiatives and roles
(as outlined above). This study follows the iterative steps
suggested by Pawson et al28 and implemented in previous
reviews undertaken by the lead author.31 32 We plan to
report our realist syntheses according to RAMESES
publication standards.33 This synthesis work will facilitate our development of an initial programme theory in
which we will hypothesise the intended outcomes of the
programme and the proposed mechanisms that bring
forth those outcomes, alongside the various contexts in
3
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Open access
which we believe these to occur. Through testing (see
phase 3), this ideally results in a ‘revised, more nuanced
and more powerful programme theory’.29 31 The steps
through which we will undertake our work are as follows:
Step 1: clarify the scope, locate existing theories and develop
programme theory
We will conduct a broad database scan to search for
existing theories, based on our own hypotheses, to help
us build our initial programme theory. We will search
through electronic published sources. We will identify
the variations of the assistant in medicine role such as
the physician assistant/associate and the assistantships in
medicine and examine how they are supposed to work
and their intended outcomes (developing initial C-M-Os).
Variations will be considered if they have considerable
overlap with the assistant in medicine role in either the
rationale for their inception (ie, to fill a physician service
gap/need) or they involve final-year medical students
learning/working in the clinical setting as they transition
into their first job. We will review initial C-M-Os, examining what these programmes achieve and also for explanations as to why such programmes do not always achieve
expected outcomes.
Our search of literature to date has identified a number
of aspects that might impact on the implementation of
the role. Some of these include role regulation, acceptance, integration, extension and support. For example,
a significant factor in the quality of the experience of an
assistant in medicine is the appropriate delegation of
substantial or significant responsibility to them, thereby
integrating them into the team. Where this has occurred
under appropriate supervision, the assistants in medicine
experienced a higher level of professional development
and preparedness. This requires an understanding of this
role within the hospital system and how it can be effectively used. By comparison, the role of physician assistant
has been hampered by a lack of a clear job description20
and ability to act with authority, leading to calls for regulation and registration within a new association.17 19 20
Confusion about these roles can severely impact on the
formation of professional identity leading to identity
dissonance.2 8
Step 2: search for evidence
Table 1 clarifies our inclusion and exclusion criteria for
the literature search. Using these criteria, we will work
with a university-based librarian to develop an appropriate
search strategy to locate articles pertinent to the roles of
assistantships in medicine, physician assistants and physician associates (box 1 is an example of this). Note that we
include the term ‘pandemic’ in our search strategy as the
assistant in medicine role was implemented in response to
the pandemic. The rationale is to see if any other similar
roles have been developed or any equivalent use of senior
medical students, during the pandemic, and how they
are being used. As the search develops, we will continue
to iteratively monitor and assess our search terms, introducing new terms as required. An additional search of
grey literature will commence if deemed appropriate, in
which we will review documentation that contains policy,
procedures and curriculum reports alongside any other
literature that may come within the scope of the study.
Step 3: study selection procedure and appraisal
We will search first for evidence-based peer-reviewed
articles and non-peer reviewed forms of literature such
as conference papers, reviews and editorials published
between 2015 and 2020. A reference list will be created
in EndNote of titles and abstracts of the literature identified. As we are undertaking a realist synthesis, we will
apply an iterative model of literature review: refining and
reviewing theoretical elements as they are formed and
developed. Any findings that are significant but stretch
the inclusion criteria will be included, and the boundaries of the preliminary inclusion criteria will be adapted
accordingly.
Step 4: data extraction and organisation
Relevant literature will be extracted in an Excel spreadsheet using realist synthesis appraisal form that includes
the following categories: author, title, year of publication,
construct under study, design, methods and findings.
The literature will be graded, as advised by the RAMESES
standards,30 according to robustness and relevance to the
programme theory, and will be checked for integrity and
reliability. In this way, we will be able to evaluate the quality
Table 1 Inclusion and exclusion criteria
Construct
Criteria
Timespan
2015–2020: exclude dates outside this range. Exception: key articles such as similar interventions due to
past pandemics that may be found outside this date range
Full research papers, editorials, commentaries, brief reports and other short pieces, book chapters and
conference proceedings. Exclude unpublished works
Reference types
Research design
All kinds of research design
Participant groups
Final-year medical students, physician associates/assistants and other types of physician assistants
designed to fill a service gap. Exclude all medical and non-medical personnel outside the inclusion range
Study contexts
Hospital sites and similar clinical learning environments (eg, ambulatory settings). Exclude all contexts
outside the inclusion range
Articles written in English. Exclude other languages
Languages
4
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
BMJ Open: first published as 10.1136/bmjopen-2020-045822 on 6 September 2021. Downloaded from http://bmjopen.bmj.com/ on February 25, 2022 by guest. Protected by copyright.
Open access
Box 1
Example of search strategy
Ovid Technologies Email Service
Search for: 1 or 18 or 19
Results: 1
Database: MEDLINE(R) including daily update (1996–current) search
strategy:
1. One assistantship*.mp. (56)
2. Two physician assistants.mp. or physician assistants/ (4178)
3. (Clinician* adj2 (associate or associates or aide or aides or assistant or assistants)).ti,ab. (74)
4. (Doctor* adj2 (associate or associates or aide or aides or assistant
or assistants)).ti,ab. (150)
5. (Clinical adj1 (associate or associates or aide or aides or assistant
or assistants)).ti,ab. (231)
6. (Physician* adj1 (associate or associates or aide or aides or assistant or assistants or extender*)).ti,ab. (3107)
7. (Medical* adj1 (associate or associates or aide or aides or assistant
or assstants)).ti,ab. (306)
8. Two or three or four or five or six or seven (5504)
9. Pandemics/ (28328)
10. Coronavirus infections/ (28137)
11. COVID-19*.mp. (24457)
12. Severe acute respiratory syndrome/ or SARS virus/ or sars.mp.
(16339)
13. Nine or 10 or 11 or 12 (42096)
14. Medical education.mp. or education, medical/ (48897)
15. Education, medical, undergraduate/ (17007)
16. Medical students.mp. or students, medical/ (35915)
17. 14 or 15 or 16 (78809)
18. 13 and 17 (310)
19. Limit eight to yr=‘2015–current’ (1898)
20. One or 18 or 19 (2262)
of the research literature and the richness of its conceptual contribution to the programme theory development.
Next, the literature will be examined by the research
team for contexts, mechanisms and outcomes. Once
identified, the data categorised according to context,
mechanisms and outcomes will be recorded in a coding
framework, and the coding will be managed using ATLAS.
ti V.8.
Step 5: data synthesis
The data will be synthesised by organising the categorised C-M-Os into themes and subthemes prioritised by
outcomes, thereby identifying patterns. We will use the
recommended conceptual tools to test and adjust the
programme theory34:
► Juxtaposing: when reviewing data presented by the
study to understand the outcome models mentioned
in another paper.
► Reconciling: understanding why differences exist
between contradictory sets of findings, which have
occurred in seemingly similar situations.
► Adjudicating the data: judging the quality of research
based on strengths and weaknesses in methodology.
► Consolidating sources of evidence: by developing a multidimensional reasoning for the intervention to explain
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
►
why there are different outcomes in particular
contexts.
Situating: to explain the differing outcomes of intervention through the varying configurations of the
context—mechanism—outcome.
Phase 2: realist evaluation
The initial part of our realist evaluation will be undertaken
in tandem with the above realist synthesis and will facilitate the development of the initial programme theory.
We will develop our initial programme theory by drawing
on the research team’s content expertise (being directly
involved in implementing the programme across one key
geographical area of NSW), considering the outcomes
we anticipate occurring, and how we believe these might
come about. As such, we will develop a practice-informed
set of C-M-Os.
As more ‘lines of enquiry’27 are identified, for example,
through interviews with key stakeholders who have been
involved in initiating and developing the Assistant in
Medicine Programme, these will be followed up, and
further literature searches will be conducted (dovetailing
onto our realist synthesis). In this way, our realist syntheses
and evaluation will be iterative by nature, allowing for an
ongoing and complex interpretation of the programme
theory and the development of middle-range theories
(ie, specific hypotheses that can be tested empirically and
have a transferable quality).29
Participants
Stakeholders participating in the realist evaluation will
comprise as below:
Programme developers (n=15) are the members of
NSW Health who originally devised the initiative, university representatives who have been involved in recruiting
and advising on the implementation of the initiative and
local health district representatives who are involved in
developing the initiative on the ground.
Assistants in medicine (n=20 for interviews and audio
diaries; n=55 for questionnaires) comprise the final-year
medical students employed by the specific local health
district we are studying.
Assistant in medicine supervisors and team members
(n=40 for interviews; n=200 for questionnaires) comprise
anyone who is working in the respective multidisciplinary
team in which assistants in medicine are embedded. This
includes interns, junior doctors, directors of medical
services, junior medical officers (who the assistants in
medicine will replace should the number of COVID-19
cases increase dramatically), junior medical officer
managers, directors of assistant in medicine and interprofessional team members (eg, nursing and allied health).
Data collection
We will use a longitudinal, mixed-method approach to
conduct the research over a period of 11 months (seven
of which will comprise the data collection phase). The
5
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Open access
6
One-off survey including an open-ended section at the end for
‘additional’ information/narratives of experiences
(December 2020)
To capture the extent to which participants agree with a set
of statements around the Assistants in Medicine Programme
(linking with the developing programme theory, in particular
focusing on outcomes)
Surveys
(August 2020 to December 2020)
Administered two times at the beginning and end of the assistants
in medicine term (August 2020 and December 2020)
To examine constructs over time and the interrelatedness of
those constructs (tolerance of uncertainty, stress, profile of
mood states, burnout and identity)
Assistant in medicine Qualitative semistructured
To explore in depth their daily experiences of working with the
supervisors and team interviews (group or individual) with assistants in medicine
members
demographics form
Longitudinal audio diaries
(including midway and exit
interview)
Longitudinal validated
questionnaires
We will begin with group interviews (time 1) and an invitation to
participate in the longitudinal audio diary study. At the end of the
assistant in medicine term (December 2020), we will undertake
exit interviews as an opportunity for further reflections. We will
contact the assistants in medicine when they have transitioned
into the workplace full time for a third interview
(February–March 2021)
To examine the day-to-day lived experiences around the
programme outcomes and how they are facilitated (including
unintended outcomes), this includes teamwork, preparedness
and identities
Assistants in medicine Qualitative narrative group
(or individual) interviews with
demographics form
Programme developer interviews will be held via Zoom at the start
of the study
(August 2020)
Qualitative semi-structured
To examine the rationale behind the programme, how it is
interviews (group or individual) with supposed to work, the aims and intended outcomes will be
demographics form
undertaken
Programme
developers
Purpose
Overview of data types
Table 2
Phase 3: analysis
The C-M-O configurations of intended outcomes will be
examined against the actual outcomes of the Assistants
in Medicine initiative. Intended outcomes will comprise
those developed during the realist syntheses as well as
data from initial interviews with programme developers.
Actual outcomes will be derived from our data collected
from the assistants in medicine themselves and those who
work with them. Thus, all data will be managed in a single
ATLAS.ti V.8 database. Working with the C-M-O codes
developed, we will compare and contrast the intended
outcomes and associated mechanisms and contexts
Data type
Procedure
Assistants in medicine, their supervisors and team
members will be recruited from five locations within
the local health district being studied (not identified for
anonymity purposes). All recruitment and data collection with participant groups will take place by researchers
electronically. Recruitment will commence as follows: the
project officer will email participants to inform them of
the study. The project officer will then forward the participant information sheet and consent form to those who
express an interest in participating and organise timetables for sessions. For the assistants in medicine, they will
also be introduced to the longitudinal audio diary part of
the data collection, with the full details being explained
to them during their interviews.
Participant group
How data will be obtained
methods used will be interviews, surveys, and audio
diaries (table 2).
Group (or, if requested, individual) interviews will be
undertaken with all participant groups. Longitudinal
audio diaries will be conducted with assistant in medicine
participants to understand the lived experiences close
to the events themselves. These will take around 10 min
per week and comprise short narrative reflections on
participants’ ongoing experiences as an assistant in medicine with a focus on preparedness for practice, multidisciplinary team working and supervision. They will be
provided with an audio diary guide prompting them what
to record and instructions on where, when and how to
send their recordings to the research team. They will be
given an option to do the recordings on their own smartphone/tablet or on a digital voice recorder supplied by
the research team.
We will also invite assistants in medicine to participate
in a longitudinal questionnaire (administered twice over
the course of their assistant in medicine employment) to
assess their perceptions of professional identity,35 teamwork,35 tolerance of uncertainty36 and burnout.37 Assistant in medicine supervisors and team members will also
be asked to complete an online survey. The survey items
will be developed based on the interview responses, and
the rationale is to measure the prevalence of experiences
that are narrated in the interviews across the participant
cohort. Box 1 summarises the rationale for data collection for each participant group.
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
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Open access
between the two sets of data (intended vs actual) to establish what worked for who, how and in what contexts. We
will employ the process of data abduction.38 Abduction
searches for an explanation of surprising results that are
not readily explained by the initial programme theory.
In doing so, we will consider new hypotheses or general
rules that might explain any given case. This is an iterative
process whereby hypotheses/rules are considered and
data interrogated, until the expected results are discovered. Through this abductive process, we will formulate
theoretical explanations based on empirical observations,
drawing heavily on existing social theory as we consider
the range of mediators for our explanations.
Data analysis
Qualitative data (interviews and audio diaries)
The audio recordings and transcripts will be loaded into
a qualitative software (ATLAS.ti V.8) where they will be
coded for data analysis. The use of ATLAS.ti V.8 will
enable us to explore patterns across the data such as the
similarities and differences in understandings and experiences across participant groups.
We will use a team-based primary-level analysis to identify outcomes (O), mechanisms (M) and contexts (C) for
the development of C-M-O configurations.27 These will be
matched to the C-M-Os from the programme developers
and realist synthesis (initial programme theory), refining
them to ascertain the ‘actual’ programme theory.
In-depth narrative analysis of selected illustrative data
sets will be conducted to shed further light onto our topic
of inquiry,39–42 in particular focusing on the outcome of
professional identities and preparedness, should we have
sufficient resources.
Quantitative data (demographics, questionnaires and surveys)
We will analyse the numerical data (Likert Scales) using
descriptive (eg, percentage, range and mean) and inferential (eg, t-tests and Analysis of Variance) approaches
where possible. Descriptive analysis will enable us to
determine the extent to which participants address the
context, mechanisms and outcomes of the Assistant in
Medicine Programme; inferential analyses will enable
us to examine significant differences in opinions/experiences across participant groups and demographics.
Appropriate non-parametric tests suitable for small
sample analyses will be used should we receive fewer
responses than expected. Other demographic categories
may be added to or removed from this analysis of C-M-O
configurations to test the developing theory. Open-ended
questions will be analysed with the same team-based
primary-level analysis as used for the qualitative data.
Patient and public involvement statement
Due to the tight timeframe, this study will be undertaken
without patient and public involvement.
Ethics and dissemination
Ethical approval to undertake this study was granted by the
Western Sydney Local Health District Human Research
Monrouxe LV, et al. BMJ Open 2021;11:e045822. doi:10.1136/bmjopen-2020-045822
Ethics Committee on 13 August 2020 (2020/ETH01745).
The outcomes of this study will inform programme developers of the impact that the Assistants in Medicine initiative has on the workplace (ie, as identified in the outcomes
of the C-M-O configurations). It will directly contribute to
the development of the initial programme theory through
an understanding of what actually happens. Our final
report will be of interest to these programme developers:
clinical schools, local health districts and policymakers in
the NSW State Ministry of Health. It is envisaged that it
will therefore affect future decision-making around the
assistants in medicine role. We will publish our findings
in peer-reviewed medical education journals and at international conferences.
Correction notice This article has been corrected since it was published. Given
name of author ‘Deborah O’Mara’ has now been spelled out.
Twitter Lynn V Monrouxe @LynnMonrouxe
Contributors Each named author has substantially contributed to the following:
Conception: LVM and PH. Drafting the work: LM and JAD. Design of the work,
revising it critically for important intellectual content and agreement to be
accountable for all aspects of the work in ensuring that questions related to the
accuracy or integrity of any part of the work are appropriately investigated and
resolved: LVM, PH, PK, CK, LM, DAO’M, AR, ST and JAD.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iDs
Lynn V Monrouxe http://orcid.org/0000-0002-4895-1812
Jennifer Ann Davids http://orcid.org/0000-0003-0861-9994
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