We used a multiple perspective mixed-methods study to examine the current arrangements for the delivery of FT in England and to examine a group of 217 foundation doctors as they proceeded through their second year of training (F2, August 2010–August 2011) in 28 NHS trusts. We were particularly interested in exploring doctors’confidence and competence during training as well as their well-being and
motivation; the impact of an ED placement on their well-being and abilities; and the quality of care that they provided.
Principalfindings
The mainfindings from our study are shown inTable 20. This chapter will explore thesefindings and discuss them in relation to evidence from other studies.
Postgraduate medical training: the theory and the reality
Postgraduate medical training has changed from the previously unstructured and service-led experience of the‘house officer’years to a more structured programme of FT accommodating over 8000 trainees in England. Collins22undertook an evaluation of this change and this report became available during the course of this study, allowing some comparisons. FT was established in 2005; our stakeholder study examined the position of the programme in itsfifth year of operation and the longitudinal study examined the reality for the trainees in its sixth year of operation.
We found that there was a strong national framework for FT across England and Scotland which was well understood by national and regional stakeholders, demonstrating the successful change to a structured programme of postgraduate development and agreeing with the Collins evaluation.22However, examining the realities of implementation at regional and trust level revealed several differences in terms of
placement quality and the amount of supervision and assessment available for trainees. There was
evidence that the training programme had good quality-assurance processes in place and the regional and national stakeholder groups were aware of some of these differences, but issues of communication and involvement of NHS trusts in placement planning and delivery were highlighted as reasons for
implementation difficulties. There was also concern expressed at the trust level in relation to the capacity of trainers to deliver the volume of training and assessments required by FT, and that this often conflicted with service delivery commitments.
We found that there was a variety of innovative placements being employed (such as general practice and palliative care or highly specialised roles such as medical biology and neonatal orthopaedics) and there was a slight variation in the length of ED placements, with some regions preferring the use of 6-month
rotations to 4-month rotations; however, this variation occurred in a minority of cases. This agreed with the pattern reported in the Collins evaluation.22
We found that one of the main areas of variation was the educational philosophy of the FT programme held by the educators and the programme implementers at trust level. National and regional stakeholders communicated a view of the programme that built on current problem-based medical education with experiential learning in the workplace, enabling development of the competency and confidence of junior doctors. By contrast, several TLs and some trainees emphasised the importance of‘specific training sessions on ED-related topics’to develop trainee competency and confidence. These differences would seem to undermine the purpose of FT, requiring the espoused needs of the programme to be fully and
widely articulated and debated both at trainee and at trust level to move FT forward. This issue has been noted previously100and would appear not to have been resolved. Collins22concluded that the FT
programme lacked an articulated and accepted purpose, especially in its second year, and we would contend that differences in educational philosophy and implementation of agreed learning outcomes are a major reason that the purpose of FT is not clearly understood.
This study shows that, according to the perceptions of F2 doctors, there is improvement in undertaking their work role throughout the F2 period. The time spent in the ED had the greatest impact on their perceived confidence and competence compared with all other placements that they experienced during the year. However, the influence of the FT programme itself is unclear given that we did not include any control areas not delivering FT for comparison. However, it is clear that, overall, F2 doctors perceived that their skills improved over time. Our study has moved the understanding of F2 doctors’training forward by exploring development across a range of placements over time, in which F2 doctors experienced various work roles in diverse patterns (such as day, night, on-call or shift working). By looking at several cohorts of F2 doctors we have been able to enlarge the scope of enquiry of postgraduate medical education
compared with studies considering only a single specialty or work pattern; this was called for in the review by Scallan.101In addition, we have developed a simple, self-report measure to assess perceived confidence and competence during training, called for by Miller and Archer.102
Variation in implementation across organisations
Our study demonstrated cross-sectional evidence of variation between trusts in the number of hours of one-to-one and close working contact with CSs, work demands and amount of teaching and support from CSs. Thesefindings validate the comments of regional stakeholders who noted variation in supervision and those of national stakeholders who were concerned that not all trainees were getting constructive
feedback on their work. In their focus groups trainees demonstrated the importance of adequate supervision in enabling them to gain confidence in their decision-making abilities, especially early in a placement, and comments about the quality of support and supervision were frequently included in the questionnaires–with examples of excellent and poor supervision being given. These data build on reviews and studies (e.g. Scallan,101Marteauet al.103) offering clear support for the need for and value of close, supportive supervision, including feedback for trainees on their abilities, to enable them to develop confidence and competence as doctors. However, the study was not sufficiently powered to reveal any objective evidence that reduced supervisor support impacted negatively on the perceived clinical competence and confidence of the doctors when directly questioned.
It would appear that two factors stand in the way of developing a strong framework of supervision within the workplace. Thefirst is the difference in educational philosophy between medical educators, supervisors TABLE 20 Summary of studyfindings
Phase 1–stakeholder study Phase 2–longitudinal study of F2 doctors l National framework of FT in place
l Variation in implementation
l Differences in educational philosophy
l Lack of clear end point to F2
l Mixed views on formal assessments
l Well-being focus only on few‘in difficulty’
l ED is a challenging learning environment
l Disagreement on outcomes of training
l Increase in confidence managing common acute conditions
l Increase in competence performing common practical procedures
l Similara
or better levels of anxiety and depression, stable over year
l Highera
levels of job satisfaction with improvement over year
l Similara
or lower levels of motivation, stable over year
l Variation in work demands and role clarity across placements
l Biggest increase in competence and confidence seen after ED placement
l Increase in anxiety and effort and decrease in extrinsic job satisfaction associated with the ED placement
l Outcome reviews suggest possible relationship between trainee anxiety, longer patient episodes and seeing fewer patients; may offer simple performance measure in the ED
and trainees that we have already discussed. Second, but probably the most important, is the fact that supervision and support are taking place in the workplace and supervisors have tofind the time and opportunity to undertake these activities, often during periods of busy service delivery. This is particularly an issue in time-pressured specialties like EM. This is an important resource issue associated with
workplace education that seems to rest solely with trusts, who are also responsible for service delivery. It is hard to ignore the comment made by a busy consultant looking at the impact that FT has had on his department:‘We are not broken yet but it is not far off–we just need more senior staff.’
Clearly a more joined-up resource between medical training and service delivery needs to be explored, particularly with senior NHS trust staff, to enable the appropriate level of supervisory support to be delivered.
Assessment of competence
An obvious focus of the support and development of trainees is the completion of their e-Portfolio of competence. This study, along with the evaluation by Collins,22shows the development of a national assessment programme. However, the stakeholder groups describe variation in implementation. National and regional stakeholders commented that the implementation of assessment was far from consistent across the regions and varied in quality between departments and assessors. Regional stakeholders noted that e-Portfolios were being used by most trainees, although there were some challenges with regard to the availability and use of information technology in various trusts. TLs recognised the importance of assessment in experiential learning but noted that feedback required delivery on a 24-hour basis,
necessitating the involvement of senior and middle-grade medical staff along with senior and practitioner nursing staff. However, the value of actually being able to observe the trainee in structured situations was acknowledged. Trainees held a balanced view of the national assessment process: some saw the value of gaining direct feedback on their competence and the opportunity to discuss individual cases with their supervisor; others felt that the format was‘too tick boxed’and, although allowing the examination of routine clinical cases, did not allow discussion of complex cases that might provide greater opportunities for learning. Thesefindings are supported by the study by Hrisoset al.,104which examined learning e-Portfolio use in one deanery between 2004 and 2005. Although direct comparisons with this study are difficult, it would appear that trainees and supervisors have developed a little more faith in the recording of experiential work-based learning in the e-Portfolio. Clearly more development work needs to be carried out with assessments to examine the balance between feedback and case discussion that is possible in a busy working environment.
One of the main criticisms of FT was the lack of a consistent framework to assess the completion of the F2 period of workplace training. Unlike the end of F1 training, which is marked by registration with the GMC, a strong outcome as it involves a shared responsibility between the deanery and the trusts,22the end of F2 training relies on the‘sign off’by TLs. National stakeholders fear that this end stage lacks focus and is not a sufficiently significant milestone for the junior doctors. Regional stakeholders are concerned that there is not a consistent approach, as with assessment, and it is likely that different sign-off criteria are required by different assessors. Qualitative comments from trainees would encourage a view that they have self-evaluated their learning over the F2 period and have acknowledged the experiences that have benefitted their practice (see comments inThe impact of the emergency department placement). There was little evidence from any of the stakeholder groups that F2 sign-off led to the identification of specific issues or‘doctors in difficulty’. It would seem that more work is needed to develop a nationally agreed scheme that marks the end of F2.
Well-being and motivation of foundation doctors
National and regional stakeholders and TLs confirmed that there were no systems in place to identify and support periods of overwork and strain for F2 doctors in general but that there was provision for those few who had been designated as‘doctors in difficulty’during their training programme. Our study was the
first to systematically examine a sample of trainees at the end of their F1 training and throughout the F2 programme.
On average, trainees reported levels of anxiety and depression that were similar to (T2) or better than (T1, T3, T4) those of a normative group of professional and technical workers. Levels of anxiety and depression did not vary significantly over time. Reported levels of job satisfaction were, on average, significantly higher than those of a normative group of doctors and other NHS staff, and overall and intrinsic job satisfaction (associated with aspects of work such as freedom to choose their own method of working and opportunity to use their abilities) were seen to increase over the period of their FT. Trainees reported lower levels of motivational effort than a group of general managers and this did not vary significantly across their training. This study has demonstrated that it is possible to systematically record levels of well-being of trainee doctors and compare these with levels found in other normative studies, enabling appropriate interpretation. It is likely that these measures could be incorporated within trainees’e-Portfolios. Robust and stable levels of well-being of foundation doctors from a number of NHS trusts are
demonstrated in this study, describing a more positive picture of trainee well-being than has been found in previous single-centre or single-measure studies (e.g. Brennanet al.,105Yateset al.106).
We examined various job-related characteristics associated with well-being across the F2 period and found that there was significant variation in work demands and role clarity across the various time points and, therefore, placements. These data were supported by qualitative comments from trainees who describe a variety of work roles: in some they are being stretched with a heavy workload (e.g. being on-call at night) whereas in others they have nothing to do and are not involved in decision-making about patients. For example:
I feel that my first F2 placement was not representative of my experiences as a doctor to date, as it was a particularly difficult job. As the SHO on ‘take’ for 3 busy admissions units I could take up to 40 referrals per 12 hour shift, and I spent a substantial amount of time doing paperwork, answering the bleep and organising the list rather than seeing patients. When the opportunity arose to learn a new skill (e.g. lumbar puncture) I was constantly being called away to do mundane tasks and training suffered as a result. The consultants, registrars and other SHOs on the unit were excellent – very approachable and supportive – it was just the nature of the job that ground me down – it was a relentless stream of clerking without any feedback as to whether your initial management was correct. This was not the fault of anybody, it was just the nature of the work, but I did find it very dispiriting. I did learn from the 4 months, but I felt that my job was 98% service delivery with very little training, hence why I have given quite negative feedback about it. By contrast, currently I am working on POSU [postoperative surgical] and my job is exactly what I hoped for. I am learning new skills, I have time to do tasks properly and give patients high quality care, the team are excellent, and I feel very well supported with plenty of teaching and other opportunities for development including ring-fenced training time.
T2 participant
I very much enjoyed my time in this placement, but the hours were just very unsociable. I think that more could have been learned if the department was not so busy – every patient that I saw, I felt I could learn something from, but there was not the time for much teaching on the shop floor.
T3 participant
I had a rotation in XX was quite frankly, dreadful. I had three consultants (one working 50% for the trust) who I would see for about an hour a day. I had no junior colleagues, hence no support. I had minimal teaching, certainly no formal teaching in the job. I was largely on my own, in a meaningless role (there is not much an F2 can do in a XX department and certainly very little responsibility or decisions you can take). I had no patients.
T2 participant
Similarly, in some placements trainees are clear about what is expected of them within their work whereas in other placements there is little direction as to what they are expected to do and ambiguity over whether
or not they are part of the medical team responsible for service delivery. Examples show that some ongoing monitoring of the trainees’work environment, as we have shown in this study, would identify issues of work demands and role clarity and, if measured at an appropriate time, enable changes to be made in placements reporting less than satisfactory learning outcomes.
From this we can conclude that the average junior doctor is likely to have comparable or better levels of well-being than other NHS workers and, on average, to expend a lower level of effort than those in managerial roles. However, before we conclude that trainees cope well with their FT, we should bear in mind that these are averaged data and within these groups there may be specific individuals who require additional support at specific times and/or in certain placements. A monitoring process using measures such as those within this study could be incorporated into the e-Portfolio, fulfilling recommendations made by Borman4and Darsi.6
Application of thesefindings would encourage regular monitoring and review of junior doctor well-being (we note that there is a general‘job satisfaction’survey within the trainee annual survey used by
deaneries; however, this would seem to be concerned with specific training-related outcomes). We see the value in two levels of assessment: at the placement level associated with the e-Portfolio and at an
organisational level within the NHS trust. This study has demonstrated an accurate and valid method of assessing trainee well-being and motivation, the outcomes of which are required by both supervisors and trainees in order to adapt and develop placements as appropriate learning experiences. Therefore, these data should not be kept at deanery level but communicated locally and swiftly to supervisors and trainees.