Annual trainee quality panels can help address bullying and other cultural and safety issues within local hospitals and training posts, say Zoe Oliphant and Iona Thorne
The Royal College of Surgeons (Edinburgh) has recently highlighted the widespread bullying of surgical trainees and its impact upon patient safety. RCSEd reported that around the time of an operation, disruptive behaviour contributes to 67 per cent adverse events, 71 per cent medical errors and 27 per cent perioperative deaths.
The Daily Telegraph has reported that trainee surgeons are being assaulted and that one in six surgical trainees suffer from post traumatic stress disorder.
Undermining comments from supervising consultants and inappropriate language potentially impact surgical outcomes and patient safety
The General Medical Council has previously recognised the significance of bullying and undermining. Professor Terence Stevenson spoke about bullying and undermining in 2015: “Having been on the frontline of medicine working alongside doctors in training, I am all too aware that this issue is not only bad for doctors, but also for patient safety”.
Surgical registrars report “feeling shaky” performing procedures after public humiliation. Undermining comments from supervising consultants and inappropriate language (including swearing at trainees) are destructive and potentially impact surgical outcomes and patient safety.
The British Orthopaedic Trainees Association and RCSEd are campaigning to eradicate bullying and undermining (#HammerItOut and #LetsRemoveIt). Trainees need the support of a national structural framework to put this vision into practice in the hospital.
Toxic learning environment
Training issues are not restricted to bullying and undermining, and affect all specialties. Half of 498 junior doctors surveyed by the Royal College of Physicians believed staff morale had a negative impact on patient safety in their workplace.
Junior doctors are struggling with little access to basic facilities, rota gaps and administrative pressures taking them away from patients. Pressures on consultant physicians reduce the time available for training and teaching the consultants and GPs of the future.
A proactive and routine system is essential for detecting and acting on concerns to sustain our workforce.
This week, NHS Providers highlighted the “mounting pressure on staff, as well as illustrating the workforce gap, with many trusts struggling to retain and recruit the staff they need to deliver high quality care for patients and service users”. A proactive and routine system is essential for detecting and acting on concerns to sustain our workforce.
In England, individual postgraduate deaneries and local education and training boards are responsible for maintaining quality in training posts for junior doctors, within the overall framework of Health Education England.
The HEE Quality Framework defines a vision with the domains, standards and expectations to demonstrate a high quality learning environment. HEE strives to enable locally developed systems to deliver year on year improvements in education, training and the learning environment.
Trainee quality panels
As junior doctors (a surgical registrar and medical registrar), we commend the annual trainee quality panel process in the South West Severn and Peninsula deaneries. We would like to share this good practice to address bullying and other cultural, safety and wellbeing issues within training posts.
Trainee quality panels ensure that training programmes for junior doctors are accountable and responsive to feedback from doctors in training.
The joint focus of the Trainee Quality Panel on Safe Working Environment and Effective Educational Environment ensures that issues around senior supervision, relationships in the team, including bullying and undermining, workload, handover processes, induction, appraisal and learning opportunities, are addressed.
The questions are administered by online survey and answers are collated to provide qualitative and quantitative data on individual training posts. Trainee quality panels meet annually for each specialty to review the survey findings, alongside the GMC survey findings.
The trainee quality panel proactively detects bullying and undermining on an annual basis and has an established mechanism for dealing with individuals, whilst protecting the affected trainee
Trainee representatives are invited from each hospital trust and attend the trainee quality panel for their specialty, together with training programme directors, lay representatives and deanery representatives.
The training programme directors collate a report which is circulated to college tutors and directors of medical education, requiring a written response. Serious concerns, including bullying and undermining, are dealt with on a case by case basis.
The deanery may meet with individuals involved and ask trusts or practices to commence disciplinary proceedings. The trainee quality panel annual reports are then made available to trainers and trainees within each specialty.
In the last few years, trainees have anonymously reported bullying and undermining to the trainee quality panels with success. The trainee quality panel proactively detects bullying and undermining on an annual basis and has an established mechanism for dealing with individuals, whilst protecting the affected trainee.
The process is entirely devolved from the Annual Review of Competence Progression. This is particularly important for surgical trainees, who are concerned that reporting issues in their training environments will impact negatively on career progression at ARCP.
Culture of openness
Clare Marx said in 2015: “Strong surgical leadership skills are needed to cultivate a culture of openness amongst surgical teams and the doctors they train. Where concerns exist doctors must be able to express them without feeling undermined or intimidated”.
Professor Jane Dacre, president of the Royal College of Physicians, has recently written to NHS trusts to emphasise that hospitals must put in place facilities and plans to protect the physical and mental wellbeing of the workforce to mitigate winter pressures.
Financial security and performance are dependent on retaining an engaged workforce
Protecting doctors in training is intrinsically linked with protecting patient safety in hospitals. Similarly, financial security and performance are dependent on retaining an engaged workforce.
NHS Providers has recommended that hospital trusts address bullying – trainee quality panels provide a robust framework for this. Trainee quality panels are also a mechanism for delivering the eight high impact actions to improve the working environment for junior doctors, published last week by NHS Improvement and NHS Providers.
The actions promote safe working and wellbeing, providing trusts with a practical toolkit for protecting and engaging junior doctors.
We recommend that training providers and hospital trusts provide and engage with annual trainee quality panels to address bullying and maintain the vulnerable workforce, through accountability and meaningful change.