Can compassionate leadership of senior hospital leaders help retain trainee doctors?

BACKGROUND: High burnout and low retention rates among trainee doctors threaten the future viability of the UK medical workforce. This study empirically examined factors that can sustain trainee doctors. METHOD: A total of 323 trainee doctors from 25 National Health Service (NHS) Trusts in England and Wales completed an online survey on their training and employment experiences. A mixed method approach was employed. RESULTS: Structural equation modelling revealed that perceived compassionate leadership of hospital senior leaders (CLSL) (i.e., doctors in senior clinical and management positions, and senior managers) is directly and negatively associated with trainee doctors' burnout and intention to quit. We propose the associations may be indirectly strengthened through two mediating pathways: increased psychological contract fulfilment (PCF) of training/organisational support and reduced worry about the state of the NHS; however, only the former is supported. The model can explain a substantial 37% of the variance in reported burnout and 28% of intention to quit among trainee doctors. Being a Foundation Year (FY) trainee was significantly associated with poor PCF and burnout. Rich qualitative data further elaborated on their experiences in terms of senior leaders' awareness of their training/working experiences, listening to and acting on. CONCLUSIONS: Active and demonstrable CLSL plays a vital role in trainee doctors' retention. It has both direct (through support) and indirect effects through improving trainee doctors' PCF to reduce burnout and intention to quit. This seems particularly valuable among FY doctors. Implications for the development and management of the medical workforce are discussed.

Role of coproduction in the sustainability of innovations in applied health and social care research: a scoping review.

BACKGROUND: Innovations such as toolkits and frameworks are developed through applied health and social care research, to address identified gaps in quality or safety of care. The intention is to subsequently implement these innovations into practice to bring about improvements. Challenges can arise from poor choice of implementation strategies or lack of alignment to local contexts. Research has identified the importance of involving and engaging patients, health professionals and other stakeholders in the design and delivery of the underpinning research, and in informing subsequent implementation. However, how and why such coproduction influences the sustainability of innovations in health and social care is unclear. OBJECTIVE: The objective of this scoping review is to identify and present the available evidence regarding the role of coproduction in the sustainability of innovations in applied health and social care research. INCLUSION CRITERIA: This scoping review includes papers related to the role of coproduction in the sustainability of innovations in applied health and social care research published in peer-reviewed journals. The review is limited to articles reporting applied health and social care research conducted in the United Kingdom. METHODS: Scopus, Web of Science, CINAHL and MEDLINE were searched for studies. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria, followed by a full-text review and data extraction. Data were extracted using a data extraction form developed by the reviewers. The completed forms were imported into NVivo and analysed using basic qualitative content analysis. RESULTS: Our review provides insight into the role of coproduction in the sustainability of innovations in applied health and social care research. Our findings highlight that sustainability is a dynamic process, supported by coproduction activities such as ongoing collaborative partnerships; these can be planned for in both the research design and implementation phases of a project.

"They say they listen. But do they really listen?": A qualitative study of hospital doctors' experiences of organisational deafness, disconnect and denial.

The sharing of information and feedback directly from service-providing staff to healthcare organisational management is vital for organisational culture and service improvement. However, hospital doctors report feeling unable to communicate effectively with management to provide evidence and affect improvement, and this can impact job satisfaction, workplace relations, service delivery and ultimately patient safety. In this paper, we draw on data elicited from a Mobile Instant Messaging Ethnography (MIME) study involving 28 hospital doctors working in Irish hospitals, to explore the barriers preventing them from speaking up and effecting change, and the impact of this on staff morale and services. We identify three major barriers, consistent with previous literature, to effective feedback and communication: (1) organisational deafness, (2) disconnect between managers and frontline staff, and (3) denial of the narratives and issues raised. We draw these together to identify key implications from these findings for healthcare managers, and suggest policy and practice improvements.

Feeling like the enemy: the emotion management and alienation of hospital doctors.

Introduction: Globally, an epidemic of psychological distress, burnout, and workforce attrition signify an acute deterioration in hospital doctors' relationship with their work-intensified by COVID-19. This deterioration is more complicated than individual responses to workplace stress, as it is heavily regulated by social, professional, and organizational structures. Moving past burnout as a discrete "outcome," we draw on theories of emotion management and alienation to analyze the strategies through which hospital doctors continue to provide care in the face of resource-constraints and psychological strain. Methods: We used Mobile Instant Messaging Ethnography (MIME), a novel form of remote ethnography comprising a long-term exchange of digital messages to elicit "live" reflections on work-life experiences and feelings. Results: The results delineate two primary emotion-management strategies-acquiescence and depersonalization-used by the hospital doctors to suppress negative feelings and emotions (e.g., anger, frustration, and guilt) stemming from the disconnect between professional norms of expertise and self-sacrifice, and organizational realities of impotence and self-preservation. Discussion: Illustrating the continued relevant of alienation, extending its application to doctors who disconnect to survive, we show how the socio-cultural ideals of the medical profession (expertise and self-sacrifice) are experienced through the emotion-management and self-estrangement of hospital doctors. Practically, the deterioration of hospital doctors' relationship with work is a threat to health systems and organizations. The paper highlights the importance of understanding the social structures and disconnects that shape this deteriorating relationship and the broad futility of self-care interventions embedded in work contexts of unrealized professional ideals, organizational resource deficits and unhappy doctors, patients, and families.

Employee silence in health care: Charting new avenues for leadership and management.

ISSUE: Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive. CRITICAL THEORETICAL ANALYSIS: Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture. INSIGHT/ADVANCE: The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice. PRACTICE IMPLICATIONS: Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care.

'Today Was Probably One of the Most Challenging Workdays I've Ever Had': Doing Remote Qualitative Research with Hospital Doctors During the COVID-19 Pandemic.

In this article we outline how a team of qualitative researchers responded to the challenging circumstances of the COVID-19 pandemic, describing how we successfully and speedily adopted remote/digital methods to research the experiences of hospital doctors. In 2020, we used Zoom to conduct qualitative interviews with 48 hospital doctors; in 2021, we used Zoom and WhatsApp to conduct a Mobile Instant Messaging Ethnography with 28 hospital doctors. We explain how we adapted to a virtual setting and provide clear insights (case study vignettes) into the additional demands on researchers and respondents, in particular, the impact on the research team. Finally, we analyse the positive and negatives of using remote qualitative methods and highlight the potential of hybrid data collection models that combine remote and face-to-face methods. We also highlight our success in communicating findings to a policy audience, important in time-critical situations, such as the COVID-19 pandemic.

A catalyst for change: Developing a collaborative reflexive ethnographic approach to research with hospital doctors during the COVID-19 pandemic.

The understanding of what ethnography looks like, and its purpose, is continuously evolving. COVID-19 posed a significant challenge to ethnographers, particularly those working in health-related research. Researchers have developed alternative forms of ethnography to overcome some of these challenges; we developed the Mobile Instant Messaging Ethnography (MIME) adaptation to ethnography in 2021 to overcome restrictions to our own research with hospital doctors. However, for ethnographic innovations to make a substantial contribution to methodology, they should not simply be borne of necessity, but of a dedicated drive to expand paradigms of research, to empower participant groups and to produce change - in local systems, in participant-collaborators and in researchers and the research process itself. In this paper, we reflect on our experiences using MIME, involving collaborative remote observation and reflection with 28 hospital doctors in Ireland from June to December 2021. After reviewing literature on ethnography in COVID-19 and general epistemological developments in ethnography, we detail the MIME approach and illustrate how MIME presents an evolution of the ethnographic approach, not only practically but in terms of its reflexive shift, its connected and co-creative foundations, and its ability to drive change in research approaches, participant life-worlds and real-world improvement.

' the way it was staffed during COVID is the way it should be staffed in real life ': a qualitative study of the impact of COVID-19 on the working conditions of junior hospital doctors.

OBJECTIVES: COVID-19 has prompted the reconfiguration of hospital services and medical workforces in countries across the world, bringing significant transformations to the work environments of hospital doctors. Before the pandemic, the working conditions of hospital doctors in Ireland were characterised by understaffing, overload, long hours and work-life conflict. As working conditions can affect staff well-being, workforce retention and patient outcomes, the objective of this study was to analyse how the pandemic and health system response impacted junior hospital doctors' working conditions during the first wave of COVID-19 in Ireland. METHODS AND ANALYSIS: Using a qualitative study design, the article draws on semi-structured interviews with 30 junior hospital doctors. Informed by an abductive approach that draws iteratively on existing literature and empirical data to explain unexpected observations, data were analysed using inductive and deductive coding techniques to identify the key themes reflecting the experiences of working in Irish hospitals during the first wave of COVID-19. We use the Consolidated Criteria for Reporting Qualitative Research to present this research. RESULTS: Our analysis generated three themes which demonstrate how COVID-19 prompted changes in medical staffing which in turn enhanced interviewees' work environments. First, interviewees felt there were more doctors staffing the hospital wards during the first wave of the pandemic. Second, this had positive implications for a range of factors important to their experience of work, including the ability to take sick leave, workplace relationships, collective workplace morale, access to senior clinical support and the speed of clinical decision-making. Third, interviewees noted how it took a pandemic for these improvements to occur and cautioned against a return to pre-pandemic medical staffing levels, which had negatively impacted their working conditions and well-being. CONCLUSIONS: Interviewees' experience of the first wave of COVID-19 illustrates how enhanced levels of medical staffing can improve junior hospital doctors' working conditions. Given the pervasive impact of staffing on the quality of interviewees' work experience, perhaps it is time to consider medical staffing standards as a vital job resource for hospital doctors and a key policy lever to enhance medical workforce retention. In a global context of sustained COVID-19 demands, pressures from delayed care and international health worker shortages, understanding frontline experiences and identifying strategies to improve them are vital to the development of more sustainable work practices and to improve doctor retention.

"I feel I have no voice": hospital doctors' workplace silence in Ireland.

PURPOSE: Workplace silence impedes productivity, job satisfaction and retention, key issues for the hospital workforce worldwide. It can have a negative effect on patient outcomes and safety and human resources in healthcare organisations. This study aims to examine factors that influence workplace silence among hospital doctors in Ireland. DESIGN/METHODOLOGY/APPROACH: A national, cross-sectional, online survey of hospital doctors in Ireland was conducted in October-November 2019; 1,070 hospital doctors responded. This paper focuses on responses to the question "If you had concerns about your working conditions, would you raise them?". In total, 227 hospital doctor respondents (25%) stated that they would not raise concerns about their working conditions. Qualitative thematic analysis was carried out on free-text responses to explore why these doctors choose to opt for silence regarding their working conditions. FINDINGS: Reputational risk, lack of energy and time, a perceived inability to effect change and cultural norms all discourage doctors from raising concerns about working conditions. Apathy arose as change to working conditions was perceived as highly unlikely. In turn, this had scope to lead to neglect and exit. Voice was seen as risky for some respondents, who feared that complaining could damage their career prospects and workplace relationships. ORIGINALITY/VALUE: This study highlights the systemic, cultural and practical issues that pressure hospital doctors in Ireland to opt for silence around working conditions. It adds to the literature on workplace silence and voice within the medical profession and provides a framework for comparative analysis of doctors' silence and voice in other settings.

"We All Really Need to just Take a Breath": Composite Narratives of Hospital Doctors' Well-Being during the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to the physical and mental well-being of doctors worldwide. Countries around the world introduced severe social restrictions, and significant changes to health service provision in the first wave of the pandemic to suppress the spread of the virus and prioritize healthcare for those who contracted it. This study interviewed 48 hospital doctors who worked in Ireland during the first wave of the pandemic and investigated their conceptualizations of their own well-being during that time (March-May 2020). Doctors were interviewed via Zoom™ or telephone. Interview transcripts were analyzed using structured thematic analysis. Five composite narratives are presented which have been crafted to illustrate themes and experiences emerging from the data. This study found that despite the risks of contracting COVID-19, many doctors saw some improvements to their physical well-being in the first wave of the pandemic. However, most also experienced a decline in their mental well-being due to anxiety, emotional exhaustion, guilt, isolation and poor support. These findings shed light on doctor well-being during COVID-19, and the ways in which they have been affected by the pandemic, both professionally and personally. The paper concludes by highlighting how doctors' work life and well-being can be better supported during and after the COVID-19 pandemic.

COVID-19 and doctor emigration: the case of Ireland.

BACKGROUND: Since the 2008 recession, Ireland has experienced large-scale doctor emigration. This paper seeks to ascertain whether (and how) the COVID-19 pandemic might disrupt or reinforce existing patterns of doctor emigration. METHOD: This paper draws on qualitative interviews with 31 hospital doctors in Ireland, undertaken in June-July 2020. As the researchers were subject to a government mandated work-from-home order at that time, they utilised Twitter™ to contact potential respondents (snowball sampling); and conducted interviews via Zoom™ or telephone. FINDINGS: Two cohorts of doctors were identified; COVID Returners (N = 12) and COVID Would-be Emigrants (N = 19). COVID Returners are Irish-trained emigrant doctors who returned to Ireland in March 2020, just as global travel ground to a halt. They returned to be closer to home and in response to a pandemic-related recruitment call issued by the Irish government. COVID Would-be Emigrants are hospital doctors considering emigration. Some had experienced pandemic-related disruptions to their emigration plans as a result of travel restrictions and border closures. However, most of the drivers of emigration mentioned by respondents related to underlying problems in the Irish health system rather than to the pandemic, i.e. a culture of medical emigration, poor working conditions and the limited availability of posts in the Irish health system. DISCUSSION/CONCLUSION: This paper illustrates how the pandemic intensified and reinforced, rather than radically altered, the dynamics of doctor emigration from Ireland. Ireland must begin to prioritise doctor retention and return by developing a coherent policy response to the underlying drivers of doctor emigration.

Hospital doctors in Ireland and the struggle for work-life balance.

Ireland has a high rate of doctor emigration. Challenging working conditions and poor work-life balance, particularly in the hospital sector, are often cited as a driver. The aim of this study was to obtain insight into hospital doctors' experiences of work and of work-life balance. In late 2019, a stratified random sample of hospital doctors participated in an anonymous online survey, distributed via the national Medical Register (overall response rate 20%; n = 1070). This article presents a qualitative analysis of free-text questions relating to working conditions (n = 469) and work-life balance (n = 314). Results show that respondent hospital doctors, at all levels of seniority, were struggling to achieve balance between work and life, with work-life imbalance and work overload being the key issues arising. Work-life imbalance has become normalized within Irish hospital medicine. Drawing on insights from respondent hospital doctors, this study reflects on the sustainability of this way of working for the individual doctors, the medical workforce and the Irish health system. If health workforce planning is about getting the right staff with the right skills in the right place at the right time to deliver care, work-life balance is about maintaining doctor wellbeing and encouraging their retention.

In Their Own Words: How Family Carers of People with Dementia Understand Resilience.

There is a growing body of research on resilience in family carers of people with dementia, but carers' voices are noticeably absent from it. The aim of this study was to explore carers' definitions of resilience and their opinions on the factors associated with resilience. Twenty-one in-depth interviews were conducted in Australia with people who were currently, or had previously been, caring for a family member with dementia. Transcripts were analysed thematically and three themes emerged: the presence of resilience, the path to resilience, and characteristics of the resilient carer. Although carers struggled to define resilience, the vast majority considered themselves resilient. Carers identified a range of traits, values, environments, resources, and behaviours associated with resilience, but there was no consensus on the relative importance or causal nature of these factors. Carers also considered resilience to be domain- and context-specific, but did not agree on whether resilience was a trait or a process. These findings highlight both the importance of including carers' voices in resilience research and the limitations of the extant literature. There is much to be done to develop a field of carer resilience research that is theoretically sound, methodologically rigorous, and reflects the lived experience of carers. A model is provided to prompt future research.

Homicidal ideation in family carers of people with dementia.

OBJECTIVE: Family carers of people with dementia have higher than average rates of suicidal ideation, but there has been no research on homicidal ideation in this population. The aim of this study was to explore thoughts of homicide in family carers of people with dementia. METHOD: A descriptive qualitative approach was taken. Twenty-one Australian carers (7 men, 14 women) participated in individual, in-depth interviews and the transcripts were analysed thematically. RESULTS: Seven themes were identified in the data - active thoughts of homicide; understanding homicidal thoughts in others; passive thoughts of death; euthanasia; homicidal thoughts in other caregiving situations; abuse; and disclosing thoughts of harm. Two of the 21 participants had actively contemplated the homicide of their care recipient, four expressed a passive desire for the care recipient's death, and four reported physically or verbally abusing the care recipient. Only one carer had previously disclosed these experiences. CONCLUSION: Homicidal ideation is a real and significant phenomenon among family carers of people with dementia. Service providers and health professionals are encouraged to identify and support carers contemplating homicide, but to do so in a way that recognises the broader social context of carer burden.