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Senior paediatric specialist registrars' experience in management
  1. Taruna Bindal1,
  2. David Wall2,
  3. Helen M Goodyear2
  1. 1Department of General Paediatrics, Alexandra Hospital, Redditch, West Midlands, UK
  2. 2West Midlands Deanery, Birmingham, UK
  1. Correspondence to Dr Taruna Bindal, Department of Paediatrics, Alexandra Hospital, Woodrow Drive, Redditch B98 7UB, UK; rano_bindal{at}yahoo.co.uk

Abstract

Background There is an increasing focus on trainees acquiring management skills which form part of college curricula and the guidance provided by the General Medical Council in the UK.

Objective To explore the managerial learning activities of senior paediatric specialist registrars (SpRs).

Design, setting, participants Questionnaire study; West Midlands region, UK; senior paediatric SpRs in the last 2 years of training.

Methods A 17 item questionnaire was sent by post to all 45 paediatric SpRs in the last 2 years of training. A follow-up email was sent to non-responders.

Results 87% (39/45) SpRs completed a questionnaire. All had participated in clinical managerial activities with 44% (17/39) doing ≥4 h per week. Popular activities were teaching and development of treatment guidelines. Non-clinical managerial experience, mainly rota management and teaching programme organisation, was limited with 64% (25/39) doing ≤30 min per week. 10% (4/39) SpRs had no experience. SpRs rated clinical and non-clinical management training as important, but only a third felt confident in managing projects or leading change. Factors which inhibited management learning were shift patterns and being too busy.

Conclusions It is essential that trainees put managerial competencies in their personal development plans and have support from their supervisors to put this plan into action, including allocated time for management training and learning. At a trainee's annual review of progress, management competencies need to be considered as well as clinical work as these are needed for a smooth transition to a consultant post.

  • Postgraduate
  • paediatrics
  • trainees
  • management
  • training
  • Health Services Administration & Management
  • Medical Education & Training
  • paediatrics
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Introduction

Medical training has traditionally focused on knowledge and skills to develop clinical competent clinicians. However, it is important that doctors also acquire managerial and leadership competencies as part of their clinician's role and in order to improve health services.1–3 The General Medical Council (GMC), UK states that “doctors are both managers and are managed”.2 The Royal College of Paediatrics and Child Health (RCPCH) higher specialist curriculum lists competencies to be acquired in leadership and management in keeping with the GMC publication Management for doctors.2 4 These management roles include clinical roles—for example, patient care in outpatients and on the wards, team working, committee working, knowledge of National Health Service structures, management of teaching programmes, educational supervision of junior trainees, clinical governance including audit, and managing service development. There needs to be knowledge of and consultation with all relevant guidance—for example, those produced by the National Institute for Health and Clinical Excellence NICE).

The importance of management training has been raised as there is an increased drive to develop clinical engagement in management to help modernise and improve the quality of health services.3 Lord Darzi's report on the NHS next stage review placed emphasis on enabling clinicians to take senior leadership and management posts in research, education and service delivery.5 Transition from trainee to consultant has been found to be a big step in various specialities when managerial experience was felt to be insufficient.6–8 In paediatrics in the West Midlands Deanery (WMD), there has been an emphasis on leadership and management experience in the final 2 years of training, although there has been the assumption that some skills are gained throughout all stages of training. Management and leadership courses are undertaken by some but not all paediatric trainees in the last 2 years of training. Although there are ways in which doctors can maximise opportunities for developing management and leadership skills,9 10 in practice this is proving to be difficult with shorter training programmes and the shift patterns of work, especially following a reduction in working hours due to the European Working Time Directive (EWTD).8

A previous UK paediatric study in 1994 looked at whether newly appointed consultants were equipped for their role and found training for management/committee work among the weakest areas.11 There have been major changes in postgraduate training in the UK since this time with the introduction of Modernising medical careers in 2007.12 We wished to look at whether WMD specialist registrars (SpRs) in paediatrics were acquiring management competencies to equip them as a consultant better than 15 years ago. In addition, the GMC guidance lists these competencies as necessary for patient and staff safety and welfare in the workplace.2 This study explored: (1) the managerial activities undertaken by paediatric speciality registrars (SpRs); (2) factors inhibiting management learning; (3) training opportunities in key management areas; (4) managerial interpersonal skills including delegation and empowering; and (5) SpRs' views on how to improve management learning during training.

Method

The study was conducted over a 2 month period (November to December 2008) in the West Midlands region of the UK. This is a large deanery, having approximately 10% of the junior doctor trainees of the UK. A 17 item questionnaire (figure 1), drawn up from the RCPCH and GMC management competencies,2 4 was posted to all 45 senior paediatric SpRs who were in the last 2 years (SpR4 and SpR5) of training (figure 2). Although speciality training (ST) was introduced in 2007, those who were SpRs remained in this grade so the UK currently has trainees with different titles. Only SpRs were advanced enough in their training to participate in this study at the end of 2008, as ST4 was the highest intake in 2007 (figure 2). All SpRs received a follow-up email 4 weeks after the postal questionnaire to target non-responders.

Figure 2

Structure of paediatric training.

The questionnaire was designed to find out which management skills trainees had gained, if they varied by subspeciality training and if there were certain competencies which were not being covered. Twelve questions had tick box responses, with five collecting demographic data and the remainder focusing on management learning and training. In addition, there were four Likert scale questions on the importance of clinical and non-clinical management experience in training, confidence in managerial interpersonal skills, and knowledge on policies/guidance used in management. The last question asked for any other comments on SpRs' management experience.

Data analysis

Data from the questionnaire were analysed to determine the types of management experiences SpRs had encountered, both clinical and non-clinical and inhibitory factors. In addition, confidence ratings for various management activities and knowledge of various key topics were evaluated using a series of six item Likert questions.

Data from all questionnaires were entered on an Excel spreadsheet and then transferred to the statistics programme SPSS version 15 for further analyses. The methods used were:

  1. Basic frequencies: for yes/no answers to the various clinical and non-clinical activities and time spent per week on each of these. They were also used for demographic data including gender, age, year of training etc.

  2. Descriptive statistics: including mean score, range, SD and 95% CIs for answers to the Likert questions Q3, Q6, Q9a through to Q9g, and Q10a through to Q10l (21 questions in all) on confidence and knowledge of various activities.

  3. Analysis of variance (ANOVA): for comparing the differences in various categories of respondent such as gender, age, year of training with responses to the Likert questions above on confidence and knowledge of various topics. A value of p<0.05 was accepted as being of statistical significance.

  4. Reliability of the answers to the 21 Likert questions (Q3, Q6, Q9a-Q9g, and Q10a-Q10l) was calculated using Cronbach's α.

  5. Free comments were analysed using the qualitative analysis programme NVivo, using a thematic analysis of coding for content of key themes emerging from the data.

Results

There was an 87% (39/45) response rate to the questionnaire. There was good internal consistency in the data from the 21 Likert questions from the respondents as a group with a Cronbach's α of 0.845. A value of 0.7 is generally regarded as acceptable for a research study and a value of 0.8 for a high stakes assessment.13

Demographic data

Of the respondents, 64% (25) were female and 36% (14) worked part time. There were 20 (51%) questionnaires from year 4, 18 (46%) from year 5 and one SpR who was post CCT (Certificate of Completion in Training) but completing the optional 6 month post following training. Trainees' specialities were general paediatrics (51% (20)), subspeciality (36% (14)), community paediatrics (8% (3)), and neonates (5% (2)). There was no difference in the management activities undertaken by SpRs in terms of gender, age, year of training and subspeciality.

Amount of managerial activity

All SpRs reported doing some clinical managerial activities with 44% (17/39)) doing ≥4 h per week (table 1). Time spent on non-clinical managerial activities was limited with most (64% (25/39) SpRs doing ≤30 min per week; 10% (4/39) SpRs had no experience. The most common factors which inhibited SpRs participating in management included shift patterns of work and being too busy (table 1).

Table 1

Summary of responses given by SpRs on management activities and training

Perceived importance of managerial activities

Clinical and non-clinical managerial experience was rated as very important in training by 90% (35/39) and 79% (31/39) SpRs, respectively, with year 5 trainees rating non-clinical managerial experience as more important than their year 4 colleagues (p=0.006). Table 2 show SpRs were least confident in leading management change and being project managers but most confident in delegation and knowing when to seek help. Female trainees were more confident to delegate to the clinical team than their male counterparts (p=0.0008). Regarding knowledge of applying policies/guidance, SpRs were least knowledgeable about E-portfolio and the National Service Framework (NSF) for children, although for the latter, year 5 trainees scored higher than year 4 (p=0.03). Trainees were most knowledgeable in work placed assessments and 360 degree feedback.

Table 2

Managerial interpersonal skills and knowledge application of policies and guidance in paediatrics

Training courses

A majority (33/39 (85%)) of SpRs reported they had undertaken training courses on key managerial areas, but 15% (6/39) had not done any formal training. Courses included ‘Teach the teacher’ (22/39, (56%)), appraisal and assessment (19/39 (49%)), leadership (15/39 (39%)) and consent (11/39 (28%)). A smaller number of SpRs had received training on how to deal with doctors in difficulty (9/39 (23%)) and E portfolio (8/39 (20%)). Ways in which trainees should be encouraged to participate in management learning are shown in table 2.

Free text comments

Seven of the 39 respondents (18%) wrote free text comments (box 1). These fell into three themes, namely time pressures and the need to have allocated time for gaining management experience, training, and courses and their availability.

Box 1 Free text comments

Time pressures

  • I believe that in order to gain experience in management we need to be ‘taken off’ the 9am–5pm activities on certain agreed days/occasions. Otherwise our colleagues, (mostly ST4s where I work currently), nursing staff, and consultants will expect us to do the SpR duties PLUS attending management meetings/acting up as consultants.

  • Plenty of management experience, problem, is as SPR no time is allocated. Therefore all in own time.

  • We need allocated time for management experience for final SpRs and specific job plan.

  • Time is a great issue.

Training

  • It is importantand& at present limited available training–it would be good to develop.

  • I have been encouraged by my educational supervisor to attend management sessions with my consultants. Formal teaching and shadowing consultants will be helpful.

Courses and their availability

  • West Midlands Stepping up to your consultant role (course) was very useful.

  • Have attended course but not one provided in West Midlands as current set up of different days over course of several months harder to obtain study leave for/fit into rota than course running over week.

Discussion

This study found that SpRs are undertaking management activities, although the time spent in non-clinical areas of management is limited. The most common factors which inhibited management learning included shift patterns of work and being busy. These are important to address as shift pattern of work is now the norm since EWTD reduced working hours to 48 h per week in August 2009.

It is perhaps not surprising that SpRs are highly involved in both organisation and delivery of clinical teaching. However, it is important for trainees to acknowledge the need to have experience in other forms of management, including clinical governance and financial planning of cost effective services. The latter especially has been reported as an area of weakness in SpR training.8 Only 13% of our trainees had experience of writing a business plan, and weakness in this area along with negotiating change and getting things done have been noted previously.7 14 In the annual survey of trainees 2008–9 performed by PMETB (Postgraduate Medical Education and Training Board, UK) trainees felt least prepared to be a consultant in the areas of planning and managing a service, leadership and dealing with managers.15

Trainees felt most confident in our study about delegation and knowing when to seek help. Lack of confidence in management leadership has been reported previously.6 8 Senior SpRs were least knowledgeable about E portfolio and the annual review of competence progression (ARCP) for paediatric trainee assessment. These are new, introduced in 2007 at the start of run through specialist training, and do not form part of SpRs assessment. However, when senior SpRs are appointed as consultants, they will have an important role to play in the educational supervision of trainees and will need to be knowledgeable about these new assessment processes and able to use them. Educational supervision is an area where SpRs find themselves poorly prepared and this has been reported by newly appointed consultants, particularly when dealing with trainees in difficulty.7 8 This has now been addressed in the West Midlands by all paediatric SpRs in years 4 and 5 being invited to attend an assessment and appraisal course, including dealing with doctors in difficulty. In addition, instead of asking trainees to leave meetings on these issues,8 it is important to include them whenever possible so that what is learnt on the course can be put into action.

Over a third of trainees had attended courses in leadership training yet this was not reflected in their perception of their interpersonal skills. It has been suggested that this is due to a lack of opportunity to practise what is learnt when a doctor does not have current managerial responsibilities.7 Year 5 trainees rated non-clinical managerial activities as more important than year 4, and this is in keeping with the finding of lack of management skills being a source of stress for newly appointed consultants.6

SpRs wanted both practical and formal training as a way to address management learning. However, management training needs to start at undergraduate level and be continued through the first two foundation years of training and then into speciality training.3 There does, however, need to be tailoring of the final years of SpR training. In higher specialist training, a post can be allocated to a first year paediatric SpR as well as a fifth year SpR, both due to choice preference, geographical location, clinical competencies that need to be gained, and availability of posts. The first step is drawing up of a personal development plan (PDP) which includes managerial competencies. Second, the trainee needs to be able to put this plan into action and as suggested by the trainees in this study have allocated time for managerial tasks. PMETB has stated that all educational supervisors must be trained by January 2010 and a number of ‘teaching the teachers’ courses have been held recently. Previously it has been felt that educational supervisors as well as trainees have prioritised clinical skills at the expense of managerial ones.8 It is hoped that the training will enable supervisors to consider more closely each individual trainees' training needs, resulting in timetabled activity for all needs to be met and for there to be different expectations for senior and junior trainees in the area of management.

At a trainee's annual review, either the RITA (record of in-training assessment) for SpRs or ARCP for ST trainees progress at obtaining the management competencies in the curriculum need to be assessed with the same emphasis as for clinical skills.8 If these are lacking then just as for clinical competencies a satisfactory outcome should not be awarded. In this way both SpRs and their supervisors will have raised awareness of management skills and enable a much smoother transition from trainee to consultant.

Main messages

  • As well as clinical work, speciality training needs to incorporate teaching and assessment of leadership and management competences.

  • SpRs recognised the importance of management experience but shift working pattern and being too busy were factors which inhibited their participation.

  • Both formal and informal management training needs to be accessible to all specialist trainees, especially those in the last few years of training.

  • Trainees' personal development plans should include gaining management competencies as well as clinical ones.

  • Senior trainees need the support of their supervisors and hospital trusts in the provision of ‘protected time’ for management activities.

  • Participation in managerial activities will help a smoother transition from trainee to consultant.

References

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Footnotes

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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