1.1 Biomedical science education in the United Kingdom

The health and care professions Council (HCPC) is the regulator of 15 health and care professions in the UK. The professions include physiotherapists and radiographers. Biomedical scientist (BMS) is the protected title of a laboratory scientist that has met the HCPC standards of proficiency. Fig 1 shows the routes to HCPC registration for BMS.

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Fig 1. The four routes to health and care professions council (HCPC) registration for biomedical scientists ‘Top-up’ education: Refers to supplementary education needed to meet the HCPC requirements.

Equivalence process: refers to the route used for laboratory scientists that work at the level of BMS and want to register as a BMS but that are not HCPC registered, (adapted from information from Institute of Biomedical Science on becoming HCPC registered [9]). COC: certificate of competence; IBMS: institute of biomedical science; HCPC: health and care professions council, BMS: biomedical scientist.

https://doi.org/10.1371/journal.pone.0268506.g001

The institute of biomedical science (IBMS) certificate of competence (COC) is a qualification that demonstrates the student/trainee meets the HCPC standards of proficiency for registration as a BMS [10]. In Fig 1 routes one and two, students will undertake an IBMS accredited undergraduate degree and laboratory training either during or after completion of the degree. Route 3 is for students that do not have an accredited degree and require educational ‘Top-up’s’, to ensure they meet the educational requirements, and clinical laboratory training. Route 4 is an equivalence route to registration. This route is not part of this research due to low numbers and a non -standardised training program.

1.2 Institute of biomedical science degree accreditation and the United Kingdom Quality Assurance Agency

Undergraduate degree accreditation by the IBMS ensures the degree covers the specified subjects, in specific depth, to meet the HCPC standards of proficiency for BMS. Degrees are only accredited if they incorporate the requirements detailed in the Quality Assurance Agency for higher education (QAA) subject benchmarking for biomedical science [11]. The accreditation process also looks at other aspects of the program, such as, program delivery and placement opportunities [12].

The QAA is an independent body that monitors and advises on standards and quality in the UK higher education. QAA benchmark statements define the academic standards that can be expected of a graduate, in terms of what they might know, do and understand at the end of their studies and describe the nature of the subject [11]. The QAA initiates regular reviews of their content, or in response to significant changes in the discipline [11]. They do not provide a national curriculum for a subject but provide general guidance for writing the learning outcomes (LOs) of the course.

POCT is referenced twice in the HCPC standards of proficiency for BMS:

1. Standard 14.16, know the extent of the role and responsibility of the laboratory with respect to the quality management of hospital, primary care and community-based laboratory services for NPT and non-invasive techniques.
2. Standard 14.26, be able to use standard operating procedures for analyses including POCT in vitro diagnostic devices

Students or trainees undertaking the COC must meet all the standards of proficiency, including the standards shown in Table 1. To become IBMS accredited, undergraduate courses only have to meet the QAA benchmarking statement.

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Table 1. The survey questions which were used to assess teaching and training of point of care testing at universities (survey 1) and national health service laboratories (survey 2).

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The QAA benchmark statement released late 2019 [11] now includes NPT under the clinical chemistry requirements. All universities seeking IBMS accreditation or re-accreditation post 2019 will have to evidence how they meet the new benchmark statement. NPT has been added to the benchmark statement “the principles and applications of biochemical investigations used for screening, diagnosis, treatment and monitoring of disease, including near-patient testing”. POCT has been added “in light of recent advances in practice”. [11]

POCT was not specifically mentioned in the previous QAA biomedical science statement [13]. This research was conducted before the new QAA benchmark statement was released in late 2019. Therefore, universities who responded to the FOI request were accredited under the 2015 benchmark statement.

1.3 Learning outcomes

LOs are a statement of what a learner is expected to know and be able to demonstrate by assessment after learning. Gosling and Moon [14] state that;

“Well written learning outcomes provide a means of mapping the content of a curriculum—for example, to see how they reflect benchmark statements, which of the key skills are acquired, where the same skill or content is appearing more than once in the programme, the capabilities the students acquire as they progress through the levels in the programme of study.”

There appears to be no standard definition of a LO, several different definitions have been suggested, see S1 Appendix [14–19]. Whilst there is no standard definition there is a conserved theme. Kennedy et al. [19], stated that the various definitions they cited did not differ significantly and it was clear that LOs focus on what the learner has achieved and what the learner can demonstrate at the end of a learning activity.

The use of LOs has been reported to have many benefits. They enable internal and external quality assurance to determine how appropriate the curriculum is [14]. The LOs allow students to gauge what they can achieve if they participate on a module/course. Mahajan and Sarjit Singh [20] listed a range of perceived benefits that in their opinion included; helping the student choose an appropriate course, give a clear idea to the students of what are they going to learn or achieve at the end of the class before the start of every class, help teachers design their teaching material more effectively, help teachers select appropriate strategies for teaching and make assessments mapping clear and easy. Given the importance of LOs throughout the years many theorists have suggested approaches to their design. Some suggested structures for a good LO are described in S2 Appendix [19, 21–24].

LOs use verbs to describe the expectations of the student. Bloom’s Taxonomy, first published in 1956 [25] and revised in 2002 [26], is often used to write LOs. It classifies thinking skills into six hierarchically organized categories that range from lower-level (know and understand) to higher-order (apply, analyze, evaluate, create) [25]. Each of the levels have indicative verbs. Stanny [27], and in previous work [28], analyzed examples of verb lists on educational websites in the United States of America and the UK respectively. Both studies found little consistency in the lists, including several verbs that appeared in all levels of the hierarchy suggested by Bloom. We have previously suggested a list of verbs to use at each hierarchical level and a list of verbs to avoid using in writing LOs [28].

1.4 Freedom of Information (FOI) requests

The UK FOI act (2000) [29] and FOI (Scotland) act (2002) [30] gives the right to access recorded information held by public sector bodies. The FOI act has some limitations about what information is covered by the act, e.g. cost above the allowable threshold, repeat of a previous request or the request is vexatious. To make a FOI request, the organisation must be contacted in writing, e.g. e-mail, letter, online form and requires your name, contact details and detailed description of the information required. The legislation allows 20 working days for a response.

FOI requests have been used as a mechanism to distribute surveys, questionnaires etc. to gather data for research. Fowler et al. [31] conducted a systematic review of the use of the UK FOI act to gather data for healthcare research. The 16 studies reviewed covered a range of requests such as litigation, surgical provision and laboratory provision. One of the studies included in the review tried to obtain data via a letter and achieved a response rate of 11%. When they made the same request via FOI the response rate rose to 83%. FOI requests have also been used in educational research. Knight et al. [32] used a FOI to look at the academic performance of graduate-entry and undergraduate medical students at a UK medical school.

Phillips et al. [33] reported a response rate between 26.6% and 100%, with a mean of 71.3% (SD 19.5%), when they looked at survey response rates in three education journals. They compared this to other reported response rates; United States of America government surveys (~ 70%), and other surveys across Europe (50–60%). Health profession education research using FOI requests have shown a response rate of 97%, 93%, 83% (Arulrajah and Steele [34], Ayton and Ibrahim [35], Copeland and Barron [36]) respectively.

The research presented here is a pragmatic approach to answer the research questions to inform further research into the BMS curriculum and laboratory training with regards to POCT teaching and training.

The current state of POCT teaching in universities and clinical laboratories is unknown and this research seeks to answer the following research questions:

1. How much POCT is taught in UK accredited undergraduate biomedical science degrees pre change in QAA benchmark statement?
2. How POCT is taught in UK accredited undergraduate biomedical science degrees pre change in QAA benchmark statement?
3. How much POCT is taught in UK pathology laboratories pre change in QAA benchmark statement?
4. How POCT is taught in UK pathology laboratories pre change in QAA benchmark statement?

2.1 Selection process

A list of UK-based IBMS-accredited degrees was obtained from the IBMS website [37]. Only UK universities were selected as the aim of the research was to identify POCT training in the UK. This resulted in 52 university FOI requests.

Despite an extensive search, there was no list of pathology laboratories in the UK. Pathology laboratories are the main provider of employment of BMS. Therefore, an FOI request was sent to every NHS acute trust or health board in the UK. To identify these, the websites for NHS England, Wales, Scotland and Northern Ireland were searched. Additionally, the public health and blood transfusion trusts for each nation were also added to the list. The trusts and health boards were selected as they host pathology as part of their organisation. This identified 179 institutions (trusts/healthboards) where FOI requests could be sent.

The FOI requests were sent to each university/trust/health board dependent on the instructions on their internet site.

2.2 Data analysis

All responses were recorded in excel for analysis. Each response was anonymised and given a unique identifier to avoid any potential reputational damage to the universities and laboratories. Response rate, response turnaround time, teaching and training hours (range, median and interquartile range) were calculated. If range of training hours was provided, then the maximum value was used.

LOs were reviewed and assessed against the following criteria:

1. Was the LO measurable?
2. Does the LO specifically describe POCT?
3. Does the LO have multiple outcomes?
4. Is the action verb used on the recommended/avoid list as described by Newton et al. [28]?
5. What level of blooms taxonomy would the verb be mapped to?

The LOs were assessed by at least one author and then reviewed by the other two authors. Any changes to the level of taxonomy assignment required agreement by all three authors.

To assign the verb to a level of blooms taxonomy, the authors used the supplementary data from Newton et al. [28]. The supplementary data includes the verb lists from 47 UK higher education institutions. Verbs were assigned to the level where it appeared in the majority of these lists.

For training hours, a day was considered to be 7.5 hours and a week 37.5 hours unless otherwise stated. When calculating median, if the respondent gave a range of time, then the highest value was used to calculate the mean. Unknown responses were not included in the calculation.

2.3 Ethics

Whilst the FOI acts allow anyone to submit FOI requests, ethics approval was obtained for the use of the FOI system in order to gather research data and the subsequent analysis and publication. (Swansea Medical School Research Ethics Committee (Project reference number 2018–0030)).

3.1 Response rate & turnaround time

For the first survey to the universities offering IBMS accredited undergraduate degrees, 100% (52) responded, while for the second survey to the UK trusts/health boards with clinical laboratories, 97% (173/179) responded.

77% (40) of the universities responded within the 20-working day limit, whilst 84% (146) of the trusts/health boards who responded did so within the limit.

3.2 Point of care testing training in universities

Fifty-two universities responded and gave results for 55 accredited degree programs. Of these, nine (16%) described their POCT teaching as embedded within the curriculum and so the teaching hours could not be quantitated. Twelve programs (22%) stated that there were no specific teaching hours dedicated to POCT.

The amount of direct teaching, non-embedded, received by an undergraduate on POCT ranged from 0 to 35 hours with a median (IQR) of 2 hours (0.25–5.75). Fig 2 shows the range of POCT teaching hours provided by the universities in response to question 2 of survey 1.

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Fig 2. Point of care testing teaching hours by number of degrees programmes on institute of biomedical science accredited degree in the United Kingdom 2018.

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When asked to provide the LO for teaching on POCT (survey 1 question 3), 29 universities (56%) responded with at least one LO. The range of LOs provided per university was 1–31 with 137 LOs provided in total. There were 192 action verbs, of which 54 were unique (see S3 Appendix).

The analysis found that of the 137 LOs, only 61% (84/137) were considered measurable. Thirteen of the LOs provided specifically mention POCT and of these 8 were measurable. See Table 2 for summary of analysis.

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Table 2. Analysis of the 137 point of care testing (POCT) learning outcomes from universities providing institute of biomedical science accredited degrees in the United Kingdom.

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Forty-seven of the provided LOs had multiple outcomes described. Forty-two of these had 2 outcomes, 1 had 3, and 4 had 4 outcomes described per LO.

We also considered whether the LO action verb appeared on the recommended/avoid list described by Newton et al. [28]. Verbs on the recommended list appeared in 49% (67/137) of LOs, whilst 26% (36/137) of the LOs had an action verb from the avoid list, see S4 Appendix.

The level of blooms taxonomy was assessed for each action verb. Of the 54 unique verbs used, 37 could be assigned to a level on blooms taxonomy, 7 were on the avoid list and 9 verbs were not found on any of the lists described by Newton et al. [28]. One verb, decide, was unmapped as it was split between the synthesis and evaluation levels, with 4 lists placing it on the synthesis and 4 on the evaluation level, see Table 3. For the full list, please see S4 Appendix.

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Table 3. Action verbs mapped to level of Bloom’s taxonomy.

The verbs were assigned using the lists collated by Newton et al. [28].

https://doi.org/10.1371/journal.pone.0268506.t003

3.3 Point of care testing training in national health service laboratories

Table 4 shows the evidence used by clinical laboratories to meet requirements for HCPC standards of proficiency 14.16 and 14.26, provided in response to question 2 of survey 2 (Table 1). Of the 173 laboratories surveyed, 118 responded. Of these, 76 gave a response for their whole organisation, with the 42 remaining laboratories giving discipline specific responses (i.e. biochemistry, microbiology). This resulted in 181 usable responses. These laboratories used 15 different types of evidence to meet the specified standards. For a breakdown between the whole trust responses and the different pathology disciplines, see S5 Appendix.

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Table 4. Types of evidence used by United Kingdom clinical laboratories to meet requirements for health and care professions council standards of proficiency 14.16 and 14.26.

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For the total number of hours spent training on POCT (Table 1, survey 2, question 3), 147 out of the 173 laboratories responded. Of these, 81 gave a response for their whole organisation, with the 66 remaining laboratories giving discipline specific responses (i.e., biochemistry, microbiology). This resulted in 254 usable data points. Table 5 summarizes the responses with S6 Appendix providing a full breakdown.

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Table 5. Summary of hours dedicated to teaching point of care testing in the national health service.

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Of the 254 responses, 37 stated they could not quantify the POCT training, with a further 66 reporting no POCT training. In the remaining 151, a range of 0–450 hours was dedicated to POCT training Overall, the median (IQR) hours for teaching POCT was 3 hours (0–7.50) for NHS clinical laboratories. In cases where a range of hours was provided by a respondent, the maximum value was used for consistency.

Fig 3, shows the different training methods used in laboratory teaching of POCT, in response to question 4 of survey 2 (Table 1). For a breakdown between the whole trust responses and the different pathology disciplines, see S7 Appendix.

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Fig 3. The different training methods used by United Kingdom national health service laboratories for teaching and training of point of care testing in 2018.

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This question yielded 225 usable responses. Several responses listed multiple training methods. As seen in Fig 3, practical training and lecture-based training was the most popular training method, with 119 and 130 responses respectively of the 372 overall responses. Thirty-four responses listed no training in POCT with 6 citing learning at university as the method for POCT training.

Question 5 of survey 2 (Table 1) asked if there was any rotation into the POCT section or department for the trainee/student. One hundred and thirty-four laboratories responded to this question with 90 responding for the whole trust. The remaining laboratories gave discipline specific information, resulting in 253 useable responses (see Table 6).

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Table 6. Summary of time spent on point of care testing rotation in United Kingdom laboratories.

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Of the 253 responses, 19 stated they couldn’t quantify how much time was spent on POCT rotation. One hundred and fifty-four responses stated that no POCT rotation took place, while a further 26 responded, not applicable. The range of hours on rotation was 0–450 hours. The median (IQR) time spent in a POCT rotation was 0 (3.75) hours. For a full breakdown of responses, see S8 Appendix.

4.1 Limitations

One of the limitations of this study is that the FOI request only went to NHS laboratories. As private businesses are exempt from the FOI act, they were excluded from the study. Eight of the respondents stated that their pathology services were run by private laboratories and so did not provide any data. These 8 responses were counted amongst the unusable returns. Another limitation is that the information provided depends on the respondent’s interpretation of the request. The FOI acts also allow respondents not to provide the information if it breaches conditions of the acts, such as cost. Two of the respondents used exemptions explicitly and several more stated that they didn’t hold the information in response to individual questions.

4.2 Conclusion

In summary, it appears that the amount of POCT taught in UK universities is extremely variable and that in the majority of universities it is taught in generic rather than specific terms.

For UK laboratory training in POCT, the trend is to provide just enough training to meet the HCPC standards, with many laboratories having no rotations in to POCT departments for practical work experience in POCT.

Further research is needed to see the impact of both an increased use of POCT and the QAA benchmark changes, in the training and teaching of POCT to students and Trainees in the UK.