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Abstract
Objective To explore the views of doctors in training about their current roles and their potential value to the National Health Service (NHS) in improving healthcare quality and productivity.
Methods Online questionnaire sent via email to 3766 junior doctors (foundation year one to specialist trainee year 3+) in the NHS South Central region.
Results The response rate was 1479/3766 (39.3%). Respondents recognised the importance of leadership (89.7%), team working (89.2%) and professionalism (97%). Only 3.4% of junior doctors stated they have never acted in a leadership capacity. However, respondents reported a lack of receptivity from their organisations: the majority responded that they do not feel valued by managers (83.3%), the chief executive (77.7%), the organisation (77.3%), the NHS (79.3%) and consultants (58.2%). 91.2% of respondents have had ideas for improvement in their workplace; however, only 10.7% have had their ideas for change implemented. Respondents who had been on a NHS South Central leadership development course were significantly more likely to feel valued by all groups of staff in their organisation. They were also significantly more likely to report having their ideas implemented.
Conclusions Doctors in training have a desire and perceived ability to contribute to improvement in the NHS but do not perceive their working environment as receptive to their skills. Junior doctors who attend leadership training report higher levels of desire and ability to express these skills. This study suggests junior doctors are an untapped NHS resource and that they and their organisations would benefit from more formalised provision of training in leadership.
- Leadership
- medical education
- quality improvement
- junior physicians
- organisational change
- adverse events
- epidemiology and detection
- continuing education
- continuing professional development
- leadership
- medical education
- quality improvement
Statistics from Altmetric.com
- Leadership
- medical education
- quality improvement
- junior physicians
- organisational change
- adverse events
- epidemiology and detection
- continuing education
- continuing professional development
- leadership
- medical education
- quality improvement
Introduction
Don Berwick, past Chief Executive Officer and President of the Institute for Healthcare Improvement, observed, “if clinical front-line staff decide they do not want to make … changes then no one outside the healthcare system can be powerful or clever enough to make them do so”1 (p. 797). At a time when UK's National Health Service (NHS) intends to transfer greater responsibility for healthcare spending to clinicians, it will be important to ensure that doctors have the desire and ability to play a significant leadership role.2 3
Doctors in training have not previously been identified as being effective agents for change in the NHS.4 However, junior doctors are exposed to a variety of working practices, through their frequent rotation between different hospitals, organisations and specialties, and therefore have the potential to disseminate good practice and identify poor practice. Bethune et al,5 commenting on the Safer Patients Initiative in England,6 7 makes the point that doctors in training could have a role in quality improvement if they were adequately equipped and informed. There is some evidence that the leadership capacity and ability of doctors in training to influence change is not being harnessed2 4 although a number of recent initiatives such as Junior Doctors: Agents for Change8 have attempted to redress this problem.
This report aims to establish the current attitudes and perceptions of a sample of junior doctors towards their role as leaders and innovators within the NHS. We also examine whether participating in leadership development programmes such as those pioneered within NHS South Central region has had an impact on junior doctors' perceptions of their own abilities to bring about improvements in the systems in which they work.
Methods
Study design
An online questionnaire was sent to all postgraduate doctors in training (from foundation year one (FY1) to specialist trainee year 3+ (ST3+)/specialist registrar (SpR) doctors) in NHS South Central.
In addition to five items of demographic information, 25 questions covering the topics of team working and leadership, professionalism, knowledge, and views on their role and their future, were constructed to evaluate the experiences of doctors in training in the NHS. These items were based on reviews of four sources of information: the Medical Leadership Competency Framework9 the literature surrounding doctors and leadership, the report on the Medical Engagement Scale10 and clinical experience. Questions were constructed to be unambiguous, answerable on a Likert-type point scale or by free text, and were phrased in the positive and negative to avoid bias.
Participants and questionnaires
The web link to the online survey was distributed via email addresses held by the NHS South Central (NHSSC) workforce and education team. This included 3766 doctors in training across South Central. The email explained the responses were anonymous and completion of the questionnaire was considered to represent informed consent. Five emails were sent out between January and June 2010.
Measures
The use of two pilot surveys was to establish the validity of the questions by feedback from respondents. Cronbach's α coefficient was estimated to determine the questionnaire reliability. Coefficients above 0.7 are acceptable.11 Univariate analyses were conducted using χ2 tests (Pearson χ2 and Fisher's Exact test). All calculations were carried out using SPSS (V.18) statistical package (http://www.spss.com).
Ethical approval
This study was considered by the Chairman of the Oxfordshire Research Ethics Committee to be a service evaluation. A full ethics review by an NHS Research Ethics Committee was not required.
Results
A total of 1479 doctors in training responded to the questionnaire (n=1479/3766, 39.3%). Basic demographic information about the respondents is given in table 1.
Grade and Specialty of Respondents
To assess internal reliability for the questionnaire, Cronbach's α coefficient was calculated as 0.795.
Questionnaire results were interpreted through the three main issues identified: desire of junior doctors to engage in leadership activities; perception of their ability to take on leadership activities; and perceptions about the receptivity of the NHS to them engaging in these leadership activities.
Desire of junior doctors to engage in leadership roles
To the question ‘How important is it for you to feel part of a team in your organisation?’, 89.2% of respondents answered ‘extremely important’ or ‘very important’. Similarly, to the question ‘To what extent do you think it's important for doctors to be effective leaders?’, 89.7% answered ‘to a very great extent’ or ‘to a great extent’. To the question ‘Do you regard yourself as a professional?’, 97.0% answered ‘yes’, 0.9% ‘no’ and 2.1% ‘maybe’.
Perceived ability and knowledge of junior doctors
The majority of junior doctors believe that they engage in leadership, with 33.5% saying that they engage daily in leadership activities and a further 42.3% answering that they sometimes act as a leader. Only 3.4% stated that they never acted in a leadership capacity.
Despite 91.2% of respondents having had ideas for improvement in their workplace, when asked about their ability to implement new ideas, their self-assessed success rate is limited, with only 10.7% saying that they had ever had an idea for change in their workplace that was implemented. Overall, 43.8% felt unsure of how to get an idea implemented or had tried and failed to do so.
In terms of their organisational knowledge, only 6% answered that they have ‘no idea’ about the organisational structure of their current organisation. However, 41% did say that they would like to know more. Junior doctors are also confident that they understand what constitutes good clinical practice, with over 80% confirming that they had a good idea what constitutes patient safety (89.6%) and patient satisfaction (81.2%).
Receptivity of the organisation
A very high proportion of respondents (83.3%) answered ‘not valued at all’ or ‘sometimes valued’ by managers to the question ‘How much do you feel valued by…’. A total of 77.7% of respondents answered ‘not valued at all’ or ‘sometimes valued’ by the chief executive to the same question; 77.3% of respondents answered ‘not valued at all’ or ‘sometimes valued’ by the organization; and 79.3% of respondents answered ‘not valued at all’ or ‘sometimes valued’ by the NHS. By comparison, respondents responded positively to feelings about being valued by consultant and non-consultant colleagues; 75.5% responded that they felt ‘highly valued’ or ‘valued’ by non-consultant colleagues and 62.8% by consultants to the same question.
A total of 39.3% of junior doctors answered that they had ‘never’ worked or collaborated with a manager during their training (figure 1). Primary care doctors in training who work significantly more frequently with managers (11.8% of primary care trainees work on a daily basis with managers versus 5.3% of hospital trainees; χ2=9.07; df=3; p=0.028) also were significantly more likely to feel valued by both managers (Fisher's exact test =21.2; p<0.001) and their organisation (Fisher's exact test =13.7; p=0.003) than hospital doctors in training.
How frequently do you work/collaborate with your organisation's management team?
Does leadership development help?
One approach to addressing the lack of confidence in junior doctors' ability to implement change is to engage them in leadership development. In this section, we provide some preliminary evidence on this by comparing the responses of those who had attended NHSSC multi-disciplinary leadership development courses and those who had not.
Respondents who had been on a NHSSC leadership course were significantly more likely to respond positively to the question ‘How much do you feel valued by…’ for all members of their organisation but not the ‘NHS’ overall (see table 2).
Comparison of responses from doctors who had attended and doctors who had not attended NHSCC leadership courses
All doctors, regardless of grade or specialty, who had attended NHSSC leadership courses were significantly more likely to have had their ideas implemented compared with doctors who had not attended the NHSSC leadership courses (χ2=20.3; df=1; p<0.001 and χ2=6.69; df=1; p=0.01, respectively).
Discussion
The findings suggest that doctors in training are already adapting to new roles within the NHS and have realised the need and desire to develop ideas and skills, such as team working, medical professionalism and leadership, whichthat are outlined in the Medical Leadership Competency Framework, and Royal College of Physicians and King's Fund publications.9 12 13 However, our survey has also shown that junior doctors feel unable to realise their full potential as change agents. While the majority of respondents have had ideas for improvement in their workplaces (91%), only 10.7% had had their ideas implemented. This discrepancy has important implications for the potential opportunities that are missed for quality improvement and may have a negative impact on the sense of worth of the employees who are unable to share their ideas14 as suggested by our finding that junior doctors in the region of the NHS surveyed do not feel valued by their organisations. If the government is to achieve the aim of improving productivity and quality in the NHS on a restricted budget then all employees need to feel valued and engaged to optimise organisational performance.15 16
Our results are in accord with the growing acknowledgement in the international literature of the vital role that physicians need to play in bringing about quality improvement and judicious use of resources.17 18 The literature recognises that medical education and the structures within which physicians work are currently inadequate to equip future clinical leaders to take on the responsibilities to lead change. Our findings suggest that leadership development of doctors in training can go some way to achieving this goal.
This study has several limitations. First, the overall response rate for the questionnaire was 39.3%. Responses rates for similar surveys of junior doctors in the UK have varied from 9% to 66%,19–22 with a general trend towards lower response rates in recent years. Second, some respondents may have filled the survey in more than once as no individual identification numbers were provided when reminders were sent due to data protection. In order to minimise this effect respondents were warned of this limitation in the email text and reminders sent out over a 5-month period. Finally, the survey instrument that we used has not been formally validated.
Caution needs to be exercised in drawing causal inferences from the differences in responses between NHSSC participants and non-NHSSC participants, since the attitudinal differences might be what motivated the respondent to attend leadership course.
We have demonstrated that the junior medical workforce have both the desire and ability to start contributing to improvement in the NHS, but feel that the environment in which they work is not sufficiently receptive to their skills. We have also shown that formal development of leadership skills is able to contribute positively to enhancing the role that this section of the workforce can undertake in healthcare improvement. The challenge for established system leaders is to acknowledge this section of the workforce's ability and to provide the right environment to nurture and apply their potential if some of the problems facing healthcare today are to be solved.
Acknowledgments
The authors would like to acknowledge Miss Vicky Osgood, Dr Marion Lynch, Dr Simon Plint, Dr Michael Goldacre, Miss Hayley Strange, Mr Alan Gilbert, Mr Don Strange and Dr Heather Champion.
References
Footnotes
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data available on request from the corresponding author.