Primary Care Physicians' Experiences With and Adaptations to Time Constraints.

Importance: The primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees' experiences and outcomes of work. Objective: To examine how time constraints affect primary care physicians' work experiences and careers. Design, Setting, and Participants: Between May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians' reflections on implications for their careers. Main Outcomes and Measures: Thematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey). Results: Interviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients. Conclusions and Relevance: These findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians' withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians.

"Good Care Is Slow Enough to Be Able to Pay Attention": Primary Care Time Scarcity and Patient Safety.

BACKGROUND: There is growing, widespread recognition that expectations of US primary care vastly exceed the time and resources allocated to it. Little research has directly examined how time scarcity contributes to harm or patient safety incidents not readily capturable by population-based quality metrics. OBJECTIVE: To examine near-miss events identified by primary care physicians in which taking additional time improved patient care or prevented harm. DESIGN: Qualitative study based on semi-structured interviews. PARTICIPANTS: Twenty-five primary care physicians practicing in the USA. APPROACH: Participants completed a survey that included demographic questions, the Ballard Organizational Temporality Scale and the Mini-Z scale, followed by a one hour qualitative interview over video-conference (Zoom). Iterative thematic qualitative data analysis was conducted. KEY RESULTS: Primary care physicians identified several types of near-miss events in which taking extra time during visits changed their clinical management. These were evident in five types of patient care episodes: high-risk social situations, high-risk medication regimens requiring patient education, high acuity conditions requiring immediate workup or treatment, interactions of physical and mental health, and investigating more subtle clinical suspicions. These near-miss events highlight the ways in which unreasonably large patient panels and packed schedules impede adequate responses to patient care episodes that are time sensitive and intensive or require flexibility. CONCLUSIONS: Primary care physicians identify and address patient safety issues and high-risk situations by spending more time than allotted for a given patient encounter. Current quality metrics do not account for this critical aspect of primary care work. Current healthcare policy and organization create time scarcity. Interventions to address time scarcity and to measure its prevalence and implications for care quality and safety are urgently needed.

' 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.

How the organisation of medical work shapes the everyday work experiences underpinning doctor migration trends: The case of Irish-trained emigrant doctors in Australia.

Medical migration is a global phenomenon. In Ireland, hospital doctor emigration has increased significantly in recent years, with Australia a destination of choice. With work and employment conditions cited as a driver of these trends, this article explores how health system differences in the organisation of medical work shape the everyday experiences of hospital doctors which underpin migration decisions. Drawing on 51 semi-structured interviews conducted in July-August 2018 with Irish-trained hospital doctors who had emigrated to work in Australia, the findings highlight doctors' contrasting experiences of medical work in the Irish and Australian health systems. Key system differences in the organisation of medical work manifested at hospital level and related to medical hierarchy; staffing, support and supervision; and governance and task coordination. Findings indicate that retention of hospital doctors is as much about the quality of the work experience, as it is about the quantity and composition of the workforce. At a time of international competition for medical staff, effective policy for the retention of hospital doctors requires an understanding of the organisation of work within health systems. Crucially, this can create working contexts in which doctors flourish or from which they seek an escape.

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.

Critical healthcare management studies: green shoots.

Purpose While critical approaches have enriched research in proximate fields, their impact has been less marked in studies of healthcare management. In response, the 2016 Organizational Behaviour in Health Care Conference hosted its first-ever session dedicated to the emergent field of critical healthcare management studies (CHMSs). The purpose of this paper is to present five papers selected from that conference. Design/methodology/approach In this introductory paper, the authors frame the contributions as "green shoots" in a field of CHMS which contains four main furrows of activity: questioning the taken-for-granted; moving beyond instrumentalism; reflexivity and meanings in research; and challenging structures of domination (Kitchener and Thomas, 2016). The authors conclude by presenting an agenda for further cultivating the field of CHMS. Findings The papers evidence the value of CHMS, and provide insight into the benefits of broadening theoretical and methodological approaches in pursuit of critical insights. Research limitations/implications CHMS works to explicate the multiple and competing ideologies and interests inherent in healthcare. As pragmatic imperatives push the provision of health and social care out of the organisational contexts and into private space, there is a particular need to simultaneously understand, and critically interrogate, the implications of new, as well as existing, forms of care. Practical implications This paper reviews, frames and details practical next steps in developing CHMS. These include: enhanced engagement with a wider range of actors than is currently the norm in mainstream healthcare management research; a broadening of theoretical and methodological lenses; support for critical approaches among editors and reviewers; and enhanced communication of critical research via its incorporation into education and training programmes. Originality/value The paper contributes to an emerging stream of CHMS research, and works to consolidate next steps for the field.

Conceptions of patients and their roles in healthcare: Insights from everyday practice and service improvement.

PURPOSE: The purpose of this paper is two-fold. First, it sets the context for the special issue by considering conceptions of patients and their roles in service delivery and improvement. Second, it introduces the contributions to the special issue, and identifies thematic resonance. DESIGN/METHODOLOGY/APPROACH: The paper utilises a literature synthesis and thematic analysis of the special issue submissions. These emanated from the Ninth International Organisational Behaviour in Healthcare Conference, hosted by Copenhagen Business School on behalf of the Learned Society for Studies in Organizing Healthcare. FINDINGS: The articles evidence a range of perspectives on patients' roles in healthcare. These range from their being subject to, a mobilising focus for, and active participants in service delivery and improvement. Building upon the potential patient roles identified, this editorial develops five "ideal type" patient positions in healthcare delivery and improvement. These recognise that patients' engagement with health care services is influenced both by personal characteristics and circumstances, which affect patients' openness to engaging with health services, as well as the opportunities afforded to patients to engage, by organisations and their employees. ORIGINALITY/VALUE: The paper explores the relationally embedded nature of patient involvement in healthcare, inherent in the interdependence between patient and providers' roles. The typology aims to prompt discussion regarding the conceptualisation patients' roles in healthcare organisations, and the individual, employee, organisational and contextual factors that may help and hinder their involvement in service delivery and improvement. The authors close by noting four areas meriting further research attention, and potentially useful theoretical lenses.