Tog 12652
Tog 12652
12652 2020;22:147–54
The Obstetrician & Gynaecologist
Education
http://onlinetog.org
a
ST7 Obstetrics and Gynaecology Trainee, St Michael’s Hospital, Bristol BS2 8EG, UK
b
Vice Chair (Education), National Royal College of Obstetricians and Gynaecologists Trainees’ Committee, Royal College of Obstetricians and
Gynaecologists, London SE1 1SZ, UK
c
ST6 Obstetrics and Gynaecology Trainee, St Michael’s Hospital, Bristol BS2 8EG, UK
d
Gynaecological Oncology Subspeciality Registrar, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham
GL53 7AN, UK
e
Consultant Obstetrician and Director of Education and Workforce, University Hospital Southampton, Southampton SO16 6YD, UK
f
Vice President for Workforce and Professionalism, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
*Correspondence: Marie O’Sullivan. Email: [email protected]
Key content Learning from excellence may be more helpful than focusing on
High-quality training environments may increase job satisfaction, negative aspects of poor training.
reduce attrition and promote excellence in education and training.
Learning objectives
Data on training are collected through the General Medical
To understand the fundamental features of highly
Council Survey, Training Evaluation Form and Workforce Survey.
Attrition rates in obstetrics and gynaecology are high (30%) –
performing units.
To identify contributors to poor training performance.
among the highest across all specialties – and reasons for this To implement a simple structure for analysing
include morale and undermining, training processes and
training performance.
paperwork, support and supervision, work–life balance, National To learn simple interventions that can improve training.
Health Service environment and job satisfaction.
High attrition rates affect the remaining workforce and can have a Keywords: education / learning environment / training
negative impact on the working environment.
Please cite this paper as: O’Sullivan M, Newell S, Frost J, Mountfield J. The key features of highly effective training units in obstetrics and gynaecology.
The Obstetrician & Gynaecologist 2020;22:147–54. https://doi.org/10.1111/tog.12652
low in mood, depressed or anxious, and 19% stating that they Royal Colleges of Physicians of the UK published quality
felt this way at least on a monthly basis.1 Recent high-profile criteria for higher levels of medical training, setting an
cases surrounding trainee involvement in adverse medical educational vision for assisting doctors in training and
incidents have led to more trainees questioning their career maximising the educational value of high-demand
choices, with some considering such cases to be a step service needs.12
backwards for patient safety and the ‘blame-free’ learning Using the JRCPTB domains,12 existing literature, national
culture.6 In addition, the debate over junior doctor contracts guidance, the Gold Guide and a national analysis of the TEF
and the associated industrial action have had a lasting impact results,4,11–18 this article proposes a checklist of quality
on the morale of the junior workforce.7 While there is no criteria that training units can use to benchmark their
clear evidence that low attrition is directly related to effective education and training against the best units in the country,
training, they are likely to be closely connected. Not all and identify ways to improve the learning environment
trainees will leave the training programme as a result of within their units (Appendix S1). These quality criteria have
negative experiences. However, the work undertaken by the been derived by members of the TEC and approved by the
RCOG on attrition has identified features, such as workload RCOG Education Board to support the new RCOG core
and stress, which are also likely to impact negatively on curriculum. The authors suggest ways that training units can
trainees’ experiences of training and education, and which improve their learning environment and trainee satisfaction.
undoubtedly increase attrition rates. Trainees are also responsible for training – their own and that
In the clinical arena, there has been a change in focus from of others – and it is hoped that this article will also help
learning by reviewing negative events and outcomes to trainees to improve culture in their own units.
learning from excellence. Positive reporting strategies have It is important to be aware that many of the difficulties
been shown to improve a positive working culture, which in faced in O&G currently do not solely affect trainees; rota gaps
itself has been associated with improved patient outcomes.8 and attrition are also prevalent at consultant level, adding a
The same use of positive reporting and learning from units further layer of complexity to providing excellent patient care
assessed as excellent may be beneficial in medical education and ongoing training. The ability to influence culture and
and training. With trainee attrition and training evaluation, raise standards is everyone’s responsibility, and working
traditionally the focus has been on identifying areas of bad together will be the key. The GMC’s National training surveys
practice, where improvement is needed.9 In 2017, the RCOG 2018: initial findings report highlighted the stark realities of
Training Evaluation Committee (TEC) shifted the focus to training and being trained in the current frontline
the lessons that can be learnt from the highly performing medical workforce:19
units, asking educators at these units to provide feedback and Nearly one-quarter of doctors in training and just over
insight into how they create effective learning environment. It one-fifth of trainers are burnt out.
was considered important to reward excellence in these units, Almost one-third of trainees said that they are often or
as well as to investigate the ways in which they provided always exhausted at the thought of another shift. Around
high-quality training. half of trainees and trainers reported that they often or
National feedback on O&G training is regularly collected always feel worn out at the end of their working day.
via the General Medical Council (GMC) Survey, the RCOG One-fifth of trainees and trainers feel short of sleep when
Training Evaluation Form (TEF) and the RCOG Trainee at work.
Attrition and Workforce Survey. These have identified the Two in five trainees and two-thirds of trainers rated the
key reasons for trainee attrition as low morale and intensity of their work as very heavy or heavy, and nearly
undermining, training processes and paperwork, support half of all trainees work beyond their rostered hours on a
and supervision, work–life balance, NHS environment and weekly or daily basis.
job satisfaction.1,9,10 A recent study assessing factors that may One-third of trainees and trainers reported that training
reduce trainee attrition identified the following key themes: opportunities are lost due to rota gaps
being valued as an individual, flexibility and predictability,
standardisation and transparency in processes to promote
Top tips from the best units
fairness, access to quality support, and learning-focused
training.9 Reducing attrition in units and retaining a well- Following a review of the TEF data, four national awards
functioning workforce may improve the training were given to the highest-ranking units across the following
and environment. domains (from 171 units):
In 2015, the Joint Royal College of Physicians Training Overall performance
Board (JRCPTB) published quality criteria for core medical Obstetric training
training, designed to enhance the educational experience of Gynaecology training
core medical trainees.11 Following this, in 2016, the three Professional development.
2017 responses
“This is important for me to know that our patients are getting great
TEF top 10 units 2017 care from satisfied doctors and these great doctors want to come back
as consultants to work with us.”
TEF top 10 units 2018
“We have focused on creating an ethos based on support and training,
and a ’culture change’. Our quality panel data was excellent in all areas,
as well as excellent in all areas for our foundation programme. We have
an exchange programme that has seen our last exchange trainee for
New Zealand coming back for a post-Certificate of Completion of
Training job, and our last ST7 also stay for a benign gynaecology
fellowship.”
“We are delighted that the trainees in Lanarkshire value the effort and
dedication of all staff in the Trust who help them achieve their personal
training goals, and that they have given us such positive feedback.”
2018 responses
2017 “. . . A functional team – treating medical students, junior medical staff
Antrim and registrars as team members and equals.”
Ulster “Continuity to ensure continuous progression of trainees during their
NHS Borders time in the unit.”
Southend University NHS Foundation Trust
NHS Lanarkshire “Turning service provision into training opportunities.”
Royal Devon & Exeter NHS Foundation Trust
“Increasing opportunities for team training and simulation.”
South Tees Hospitals NHS Foundation Trust
Worthing & Southlands Hospitals NHS Trust “[We have] at least maintained our strong reputation for 2 years in a
Craigavon Area row. We have all put in a lot of work over the last 8–9 years or so. . .and
Peterborough & Stamford Hospitals NHS Foundation Trust have successfully ‘turned around’ a unit that was having problems a
few years ago.”
2018
Southend University NHS Foundation Trust
Peterborough & Stamford Hospitals NHS Foundation Trust
Dartford & Gravesham NHS Trust
Lancashire Teaching Hospitals NHS Foundation Trust units. They were asked: ‘What makes you particularly proud
Western Health & Social Care Trust with regard to training and education within your unit?’ and,
Northern Health & Social Care Trust ‘If you could pick three top tips for success to share with
NHS Lanarkshire
NHS Borders
other units, what would these be?’ The responses received are
Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust summarised in boxes 1 and 2.
Poole Hospital NHS Foundation Trust The same educators were also asked, ‘what could you do to
improve education and training even more?’. Box 3 shows
Figure 1. Map showing the best performing units based on 2017/18
the responses from the educators at the best units in 2017
Training Evaluation Form (TEF) data.
and 2018.
Trainees complete the GMC Training Survey every year,
The top ten performing units for 2017 and 2018 can be and the results from the TEF are cross-referenced to ensure
seen in Figure 1.18 that units score consistently in the subsequent survey. The
The next top nine units in each domain were ‘highly overall winner in 2017 was Antrim, and in 2018 it was
commended’, and feedback was sought from all of the top ten Southend University NHS Foundation Trust.
Box 2. Summary of responses from the educators at the units Box 3. Summary of responses from the educators at the units
where trainees had given the best RCOG Training Evaluation Form where trainees had given the best RCOG Training Evaluation Form
scores in 2017 and 2018 when asked, ‘If you could pick three top scores in 2017 and 2018 when asked, ‘What could you do to
tips for success to share with other units, what would these be?’ improve education and training even more?’
“Take every opportunity to teach – be innovative.” “Minimise the hoops to be jumped through to become or to remain an
Educational supervisor.”
“Develop a meaningful induction.”
“Don’t rest on your laurels.”
2018 responses
“Trainee-centred unit.”
Figure 2. Results of the 2018 Training Evaluation Form showing the correlation between ‘Education – Support and supervision’ and ‘Overall
recommendation’.
Figure 3. Results of the 2018 Training Evaluation Form showing the correlation between ‘Working environment’ and ‘Overall recommendation’.
and experience of good behaviours are all positively other national bodies largely fit into the three themes used in
correlated with the overall recommendation of a unit. Of this model.
the overall top ten units in 2018, four were in the top ten for
‘Education – Support and supervision’, four were in the top
Community
ten for ‘Working environment’ and five were in the top ten
for ‘Behaviours experienced’, indicating that these are strong Trainees need to feel they are part of a community where
indicators of a good training environment within a unit. education is priority and which offers a sense of belonging. In
Rota gaps and lack of opportunities to attend Advanced the best units, people spoke of striving for cohesion and
Training Skills Module sessions or specialist clinics harm the committing time and effort to achieving this. This goes
training experience and are reasons for attrition cited beyond teamworking – it is a truly working community.
by trainees. Units need a sense of identity and joint ownership over
In the early 2000s, three themes were proposed that were things that occur. Fellowship, wellbeing, safety and trust are
associated with a high-quality educational environment, and paramount. Trainees can often bring fresh ideas and
these are shown in Figure 5.20 What is interesting about this enthusiasm to units and their contributions to the
model is that it remains relevant to modern educational community should be valued. Although rotating through
practice, and the information gathered from highly effective units can be difficult, trainees have a responsibility to become
O&G units and the initiatives suggested by the RCOG and involved in the community of a unit, taking responsibility
Figure 4. Results of the 2018 Training Evaluation Form showing the correlation between ‘Behaviours experienced’ and ‘Overall recommendation’.
Criticality
Criticality appears to be part of what makes professional people
A sense of
professionals. There may not be a right or wrong answer, but
community
professionals exercise their own judgement based on ‘practical
wisdom’ or ‘practical reasoning,’ thereby becoming reflective
practitioners. Trainees should be given time to discuss clinical
situations without feeling interrogated, but with guided
questioning to advance their thinking. Trainees should take
advantage of consultants’ wisdom and cultivate mentorship,
The highly
educational while consultants should value trainees’ perspectives as they
environment often view a unit through fresh eyes. Time should be made for
colleagues to reflect and think critically about their work. The
‘learning through excellence’ movement encourages
A commitment A culture of appreciative inquiry: asking questions to search for the best
to criticality collegiality in people and organisations and realising the resources and
potential within, for example, a training unit.21
A collaborative document from the Faculty of Medical
Leadership and Management, NHS Providers and NHS
Figure 5. Model showing the proposed three themes associated with
a high-quality educational environment.18
Improvement outlines eight high-impact actions (Box 4) to
improve the working environment for junior doctors.
Working with trusts and junior doctors, they have focused
not only for patient care, but also for their own learning. on ways to encourage engagement by junior doctors and
Trainees need to see themselves as part of the team, working developed actions that are meaningful and can be
together with all members of staff. initiated immediately.13
On the basis of these sources, as well as the feedback from
the best units across the UK, the Quality Criteria for
Collegiality
Obstetrics and Gynaecology Doctors in Training have been
Collegiality is more than corporate belonging; people should developed by the RCOG to support the roll-out of the new
feel they are colleagues more than staff, where they become a core curriculum. These can be seen in Appendix S1. These are
body of colleagues with a shared moral endeavour. There not designed to be standards that units must achieve or else
should be mutual acceptance and respect between face punishment, but a checklist against which units can
consultants and trainees, and this is a two-way process. benchmark themselves. If a unit can meet most of the quality
Units should feel they are not only working together, but also criteria, the authors propose that it is likely that the learning
learning together. environment within the unit will be good.
Acknowledgements
Conclusion
The authors would like to thank Karen Brackley and Sonji
While it is important to tackle negative behaviours, Clarke for their contributions to writing the Quality Criteria
particularly the unacceptably high levels of bullying and and the whole Training Evaluation Committee for their
undermining in O&G,22,23 a lot can be learned from the tireless efforts to collect, analyse and disseminate data to
positive actions of the best performing training units. improve training.
Attrition rates among O&G trainees in the UK are high,
and this is concerning for the future of the workforce and of Supporting Information
women’s health. Many factors have been identified as
contributing to attrition, and a good learning environment Additional supporting information may be found in the
not only reduces attrition but improves patient safety.8 Many online version of this article at http://wileyonlinelibrary.
of the factors that increase attrition will also have an impact com/journal/tog
on training and education, so although separate issues, Appendix S1. Training unit quality criteria for obstetrics
initiatives to tackle one are likely to help with the other. Units and gynaecology.
suffering from high attrition rates are also likely to struggle to
provide effective training to the remaining workforce due to
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