Gill Morrow

Workplace bullying in the UK NHS: a questionnaire and interview study on prevalence, impact and barriers to reporting

Objectives To examine the prevalence and impact of bullying behaviours between staff in the National Health Service (NHS) workplace, and to explore the barriers to reporting bullying. Design Cross-sectional questionnaire and semi-structured interview. Setting 7 NHS trusts in the North East of England. Participants 2950 NHS staff, of whom 43 took part in a telephone interview. Main outcome measures Prevalence of bullying was measured by the revised Negative Acts Questionnaire (NAQ-R) and the impact of bullying was measured using indicators of psychological distress (General Health Questionnaire, GHQ-12), intentions to leave work, job satisfaction and self-reported sickness absence. Barriers to reporting bullying and sources of bullying were also examined. Results Overall, 20% of staff reported having been bullied by other staff to some degree and 43% reported having witnessed bullying in the last 6 months. Male staff and staff with disabilities reported higher levels of bullying. There were no overall differences due to ethnicity, but some differences were detected on several negative behaviours. Bullying and witnessing bullying were associated with lower levels of psychological health and job satisfaction, and higher levels of intention to leave work. Managers were the most common source of bullying. Main barriers to reporting bullying were the perception that nothing would change, not wanting to be seen as a trouble-maker, the seniority of the bully and uncertainty over how policies would be implemented and bullying cases managed. Data from qualitative interviews supported these findings and identified workload pressures and organisational culture as factors contributing to workplace bullying. Conclusions Bullying is a persistent problem in healthcare organisations which has significant negative outcomes for individuals and organisations.

Preparedness for practice : the perceptions of medical graduates and clinical teams

Background: Earlier research indicated that medical graduates feel unprepared to start work, and that this varies with medical school. Aims: To examine the extent to which graduates from different UK medical schools differed in their perceptions of preparedness for practice, and compare their perceptions with those of clinical team members. Method: An anonymous questionnaire assessing perceptions of 53 aspects of preparedness was devised, and administered to the graduating cohorts of three medical schools: Newcastle (systems-based, integrated curriculum); Warwick (graduate-entry) and Glasgow (problem-based learning). In addition, a triangulating questionnaire was cascaded via ward managers to doctors, nurses and pharmacists who worked with new graduates in their first posts. Results: The response rate for the cohort questionnaire was 69% (479/698). The overall mean preparedness score was 3.5 (on a five-point scale), with no significant difference between schools. On individual items, there were large differences within each site, but smaller differences between sites. Graduates felt most prepared for aspects of working with patients and colleagues, history taking and examination. They felt least prepared for completing a cremation form, some aspects of prescribing, complex practical procedures and for applying knowledge of alternative and complementary therapies, and of the NHS. A total of 80 clinical team questionnaires were completed, similarly showing substantial variation within each site, but smaller differences between sites. Conclusions: New doctors feel relatively unprepared for a number of aspects of practice, a perception shared by their colleagues. Although medical school has some effect on preparedness, greater differences are common across sites. Differences may reflect hidden influences common to all the schools, unintended consequences of national curriculum guidance or common traits in the graduate populations sampled. Further research is needed to identify the causes.

Newly qualified doctors’ perceptions of informal learning from nurses: implications for interprofessional education and practice

Abstract Newly qualified doctors spend much of their time with nurses, but little research has considered informal learning during that formative contact. This article reports findings from a multiple case study that explored what newly qualified doctors felt they learned from nurses in the workplace. Analysis of interviews conducted with UK doctors in their first year of practice identified four overarching themes: attitudes towards working with nurses, learning about roles, professional hierarchies and learning skills. Informal learning was found to contribute to the newly qualified doctors’ knowledge of their own and others’ roles. A dynamic hierarchy was identified: one in which a “pragmatic hierarchy” recognising nurses’ expertise was superseded by a “normative structural hierarchy” that reinforced the notion of medical dominance. Alongside the implicit learning of roles, nurses contributed to the explicit learning of skills and captured doctors’ errors, with implications for patient safety. The findings are discussed in relation to professional socialisation. Issues of power between the professions are also considered. It is concluded that increasing both medical and nursing professions’ awareness of informal workplace learning may improve the efficiency of education in restricted working hours. A culture in which informal learning is embedded may also have benefits for patient safety.

Are specialist registrars fully prepared for the role of consultant

The step-up from specialist registrar (SpR) to consultant has been acknowledged by doctors as being large. It can involve relatively sudden change, and can be both stressful and demanding.1,2 There is increasing pressure on available time for training, with shortened training programmes and fewer hours spent at work as a result of the European Working Time Directive.2,3 Medical education research has not fully addressed this transition or explored ways of improving it for the benefit of patients and doctors. Newly appointed consultants are more prepared for some aspects of their work than others. The quality of training in clinical skills is rated most positively, although even this has room for improvement.2,4 New consultants feel less well prepared for their management responsibilities than they do for clinical work,2,4,5 including self-management.6 Training and experience in handling complaints, dealing with difficult professional relationships, recruitment and disciplinary proceedings have also been identified as weaker areas of specialty training.5,6 Feeling inadequately trained in communication and management skills can impact on stress, burnout and the mental health of consultants.4,7 It is notable that two-thirds of cases referred to the National Clinical Assessment Service (NCAS) involved behavioural issues (including difficulties with colleagues), either on their own or in conjunction with other concerns.8 In the light of these issues, a research project was developed to determine the extent to which specialty training provides doctors with the skills they require when they become consultants.

Cultural dimensions in the transition of overseas medical graduates to the UK workplace

Background: Historically, overseas-qualified doctors have been essential for meeting service needs in the UK National Health Service (NHS). However, these doctors encounter many cultural differences, in relation to training, the healthcare system and the doctor-patient relationship and training. Aim: To examine whether Hofstedes cultural model may help us understand the changes doctors from other countries experience on coming to work in the UK, and to identify implications for supervisors and clinical teams. Method: Telephone interviews were conducted with overseas medical graduates before starting work as a Foundation Year One (F1) doctor, followed up after four months and 12 months; and with educational supervisors. Data were analysed using a confirmatory thematic approach. Results: Sixty-four initial interviews were conducted with overseas doctors, 56 after four months, and 32 after 12 months. Twelve interviews were conducted with educational supervisors. The changes doctors experienced related particularly to Hofstedes dimensions of power distance (e.g. in relation to workplace hierarchies and inter-professional relationships), uncertainty avoidance (e.g. regarding ways of interacting) and individualism-collectivism (e.g., regarding doctor-patient/family relationship; assertiveness of individuals). Conclusion: Hofstedes cultural dimensions may help us understand the adaptations some doctors have to make in adjusting to working in the UK NHS. This may promote awareness and understanding and greater ‘cultural competence’ amongst those working with them or supervising them in their training.

Asking the right questions and getting meaningful responses: 12 tips on developing and administering a questionnaire survey for healthcare professionals

Questionnaires provide a useful and versatile tool for new and occasional researchers, and can be applied to a wide range of topics. This paper provides simple guidance on some of the potential pitfalls in developing and running a questionnaire study, and how to avoid them. Each tip is illustrated with a real-life example from the development of a UK-wide questionnaire survey of trainee doctors and their educational supervisors.

Have restricted working hours reduced junior doctors' experience of fatigue? A focus group and telephone interview study

Objective To explore the effects of the UK Working Time Regulations (WTR) on trainee doctors’ experience of fatigue. Design Qualitative study involving focus groups and telephone interviews, conducted in Spring 2012 with doctors purposively selected from Foundation and specialty training. Final compliance with a 48 h/week limit had been required for trainee doctors since August 2009. Framework analysis of data. Setting 9 deaneries in all four UK nations; secondary care. Participants 82 doctors: 53 Foundation trainees and 29 specialty trainees. 36 participants were male and 46 female. Specialty trainees were from a wide range of medical and surgical specialties, and psychiatry. Results Implementation of the WTR, while acknowledged as an improvement to the earlier situation of prolonged excessive hours, has not wholly overcome experience of long working hours and fatigue. Fatigue did not only arise from the hours that were scheduled, but also from an unpredictable mixture of shifts, work intensity (which often resulted in educational tasks being taken home) and inadequate rest. Fatigue was also caused by trainees working beyond their scheduled hours, for reasons such as task completion, accessing additional educational opportunities beyond scheduled hours and staffing shortages. There were also organisational, professional and cultural drivers, such as a sense of responsibility to patients and colleagues and the expectations of seniors. Fatigue was perceived to affect efficiency of skills and judgement, mood and learning capacity. Conclusions Long-term risks of continued stress and fatigue, for doctors and for the effective delivery of a healthcare service, should not be ignored. Current monitoring processes do not reflect doctors’ true working patterns. The effectiveness of the WTR cannot be considered in isolation from the culture and context of the workplace. On-going attention needs to be paid to broader cultural issues, including the relationship between trainees and seniors.

Self-directed learning groups: a vital model for education, support and appraisal amongst sessional GPs.

(2012). Self-directed learning groups: a vital model for education, support and appraisal amongst sessional GPs. Education for Primary Care: Vol. 23, No. 4, pp. 270-276.

Educational dimensions of life as a sessional GP: a 20-year journey.

Sessional GPs, once perceived as an under-class, are growing in numbers and therefore importance. They have been receiving particular attention due to the need for a ‘one size fits all’ model for revalidation which is objective, fair, and equitable without being overly onerous. A number of changes have had significant influence on the creation of sessional (non-principal) GP working options and expansion of their numbers: PMS (Personal Medical Services), the new GMS (General Medical Services) contract, the Flexible Career Scheme, retainer scheme, Career Start type schemes and returner (now termed ‘refresher’) schemes. There is evidence that at least half of sessional GPs work in this way out of a positive choice and not, as often described in the 1990s, because of lack of skills, confidence or ambition. Some may see this as a transitional phase but many do not. Whilst sessional GPs today grapple with many issues identified in a systematic way as far back as 1998, namely isolation, lack of access to education and information and low status, there can be no doubt that their status has improved dramatically since that time as understanding of this group of doctors has grown. They are not only less invisible as a group, having grown in number and been incorporated into local practitioner lists (subsequently supplementary lists and then performers’ lists), but the amount written about them as a result of research has increased as well. The GPC (General Practitioners Committee) model salaried contract introduced a weekly session of protected continuing professional development (CPD) in 2004, and the increased availability of e-learning has benefited sessional GPs as, unlike much traditional education, it is not restricted to practice-based GPs. In the 1990s a number of deaneries carried out surveys into the educational issues affecting non-principals. The largest and most well known, covering 598 non-principals, with a response rate of 80%, was published by the Standing Committee on Postgraduate Medical Education (SCOPME). The survey revealed a variety of problems: isolation, low status, poor peer support, financial insecurity and a ‘triple whammy’ of disincentives limiting access to education: loss of income, childcare costs and course fees. As well as difficulties accessing education, these GPs also had problems accessing professional peer support (mentoring, careers advice, opportunities for career development). There was also confusion among non-principals regarding eligibility for, and availability of, funding for education. The SCOPME survey was repeated in 2000 and its findings showed encouraging improvements in a number of areas. More respondents had contracts of employment, isolation had reduced, and this tied in with greater contact with local tutors and postgraduate centres and non-principal groups. Access to education remained a problem, attributable to loss of income as before, but many more sessional GPs had personal development plans (PDPs) (Walls D, personal communication, May 2010). Important developments were clearly beginning to have an impact, namely the advent of non-principal groups which were increasing in number thanks to the steer of the National Association of Sessional GPs (NASGP), and the increasing number of deanery-led initiatives supporting non-principals. These included return to practice initiatives, Career Start and other supported salaried schemes, and the creation of dedicated educationalists supporting non-principals. A series of conferences brought together educators working with sesEducation for Primary Care (2010) 21: 347–51 # 2010 Radcliffe Publishing Limited