Gersten Jonker

60   Chapter 3 clinical reasoning and management of unobserved situations [29]. Second, supervisors should provide legitimate workplace roles [34] by allowing students to perform observable and assessable acute care tasks (e.g. Take a focused history of a dyspneic patient). Furthermore, simulation training and assessment could be incorporated in the ACTY curriculum to guarantee a certain level of exposure to critically ill patients. Implementation research studies how interventions produce impact within real world conditions, starting with the users of the intervention (here: students and faculty) and taking contextual factors into account [22]. Looking through an implementation research lens at the experiences with the ACTY, we can say that the delivery as intended has beenwell with regards to the aims of focusing learning andproviding coherence.This may be explained by the acceptability, or relative advantage, of the thematic approach of the ACTY and the appropriateness, or perceived relevance, of the theme of acute care [22]. On the other hand, while adoption, i.e. the intention to try the intervention, is high in the workplace, delivery as intended has been hampered by lack of attention to feasibility and integration in the actual workplace settings [22]. We hypothesize that the hampering effect of limited implementation in the workplace may have been partly offset by the proactive role of the motivated students. Increasing penetration [22] of ACTY curricular ideas into daily clinical work of the students will be the focal point of improvement strategy. With the advent of the new EPA-based Utrecht undergraduate curriculum [16,17] working with EPAs will be everyday practice in departments hosting clinical students and this will ease the full implementation of advanced EPAs in the ACTY. This study on the delivery and adoption of a dedicated transitional year has strengths and limitations. A strength is that we took several measures to enhance dependability, credibility, and confirmability [35]. The data collection methods were developed by two authors in close collaboration with the other authors and were piloted. The two researchers collecting the data managed data confidentially, analyzed data separately, and checked extracts of the interviews with participants. A limitation of this study is that it was an appreciative inquiry into the implementation of this program, rather than a curriculum evaluation or a study on the efficacy of the program. As such, data only provide insight in the delivery of the program. Nevertheless, the identification of important factors associated with success and challenges of a design for the final year of medical school may well be transferable to other settings.