An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]

Abstract

BackgroundA major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.ObjectivesThis study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.MethodsPhase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).ResultsPhase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.ConclusionsThere are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

A longitudinal study of well-being, confidence and competence in junior doctors and the impact of emergency medicine placements

“…An evaluation of FT placements showed some offered greater access to front-line decision-making and clinical care (eg, EM, acute medicine) while other placements involved routine ward-based work and less decision-making. 11 As a result of this work, and the previous research cited suggesting high stress levels of junior doctors in the ED, 5 8 we reasoned there was likely to be more effort and anxiety associated with the increased decision-making and unpredictable workloads identified in ED placements, but that increased clinical exposure in ED placements may also be associated with improved competence, confidence and job satisfaction for junior doctors. Specifically this study aimed to test the following hypotheses: (a) well-being measures of anxiety and depression of junior doctors would increase (ie, worsen) significantly as a result of their placement in ED in comparison to their placements in other specialties, and (b) motivational effort and job satisfaction, confidence and self-reported competence of junior doctors would show significantly greater improvement as a result of their placement in ED in comparison to their placements in other specialties.…”

“…While there are limits to the conclusions about doctor's abilities that can be drawn from self-reported confidence and self-reported competence alone, there is also evidence that a subsample of this cohort of junior doctors are providing care that is of a good quality. 11 …”

Anatomy, radiology, and practical procedure education for foundation doctors in England: A National Observational Study

“…A recent study of 658 junior doctors of all grades below consultant (FY1‐ST7) regarding lumbar puncture procedural training found only 23% had attended an organized teaching event, indirectly demonstrating the limited access to teaching opportunities (Defres et al, ). A large review of foundation training in the United Kingdom found ongoing challenges in delivering high‐quality training at the local level, especially in time‐pressured specialties such as emergency medicine (Mason et al, ). One issue to overcome is the lack of appropriate facilities which was clearly identified as a major reason for the lack of practical procedure training.…”

Editorial

“…Her doctoral studies were nested within this project examining well-being in health care teams (Carter & West, 1999). She continues her research in health care organizations examining the: work of Emergency Departments (Mason et al, 2006, Goodacre, Campbell & Carter, 2015Macintosh, Goodacre & Carter 2010;Weber, Mason, Carter & Hew, 2011), implementation of angioplasty (Carter, Wood, Goodacre, & Stables, 2010); development of junior doctors (Mason, O'Keefe, Carter, O'Hara, & Stride, 2013), and currently, cross-boundary working to reduce avoidable admissions and attendances.…”