For educators and trainers involved in supporting trainees
Prof Selena Gray – Deputy Postgraduate Dean SPGME
Dr Adam Malin – Associate Dean for Professional Support (Severn PGME)
Ms Tailte Breffni – Support and Development Manager (Severn PGME)
Dr Hiu Lam – Associate Postgraduate Dean (Peninsula PGME)
Ms Sarah Roberts – Faculty and Professional Support Unit Administrator (Peninsula PGME)
Acknowledgements and Introduction
Health Education England Postgraduate Medical Education (PGME) Professional Support and Well-Being Teams (Severn and Peninsula) provide advice and guidance to trainees who have self-referred or been referred to the service for additional support during their training programme. Further information on who we are and what we do can be found on our websites:
Trainee Support aims to help promote trainee well-being and personal development by providing support and assistance in tackling obstacles that they may be facing, be it in their professional or personal lives. We have developed this guide for trainers involved in supporting trainees at a local level as a resource to ensure appropriate support and action has been provided.
The following guide has been developed from advice offered in the NACT guidelines and also advice offered by NHS Resolution (formerly NCAS) through their ‘Back on Track’ framework. We would therefore like to express our thanks to these bodies for their helpful documentation.
This guide offers a practical framework on how to support trainees who have been experiencing difficulties or obstacles during their training programme. It is aimed at those responsible for the education and supervision of trainees in any of the training programmes offered within the HESWPME. This guide might be useful to:
- Educational and Clinical Supervisors
- Heads of School
- Directors of Medical Education
- GP Educators
- Specialty (College) tutor
- Training/Foundation Programme Directors
Aim of this guide
Roles and Responsibilities
Three-Level Trainee Support Framework
This level represents trainees with minor concerns or dilemmas, presenting a potentially low risk to patients, themselves or others, for which a formative developmental approach is appropriate. For example, trainees who are missing some information from their e-portfolio or who have failed to obtain the required response rate for Multi-source Feedback (MSF).
These trainees will be primarily supported by their Educational or Clinical Supervisor with support from the appropriate School and / or the local Director of Medical Education. Educators and supervisors should use this guide to assess and document what support and actions have been put in place for the trainee at this level (see Appendix 1).
The local Director of Medical Education should always be kept informed of any local issues in line with local trust processes and policies.
The trainee concerned is unlikely to require extension of training period.
This Level represents trainees with issues that, if left undetected or unresolved could pose a moderate risk to the individual trainee, patients or the organisation, but are not yet sufficiently serious to warrant disciplinary action. For example, trainees who need to develop a particular clinical competence area (e.g. ARCP outcome 2 or 5), or who are showing signs of poor health.
At this stage advice and guidance should be sought from the Programme Director, Associate Postgraduate Dean (GP), Head of School or Director of Medical Education. Advice can also be obtained from Human Resources, Occupational Health and the Trainee Support team at any stage for specialist support and development opportunities for the trainee.
The trainee concerned may require extension of training period.
This level represents trainees with serious concerns and/or repetitious performance issues for which specialist input and resources are appropriate. Examples can include repeated absence from work without explanation, poor relationships with colleagues or visible signs of stress and anxiety.
Issues at this level may also represent a high level of risk to patients and others and therefore require a skilled approach. At this stage, you can recommend and advise the trainee to contact the Professional Support and Well-Being Teams at Severn or Peninsula PGME so that they can access further support and development resources. It will also be appropriate to ensure that Human Resources and your Medical Director are aware of the serious concerns raised. In some extreme cases, suspension from work may need to be considered in order to protect patient safety and indeed the safety of the trainee.
It is important that you remain closely involved through liaison with HESWPME while this support is being put in place and good communication should be maintained at every stage.
**Patient safety issues MUST be reported to the DME as soon as they become apparent so that they can inform the MD. Trust HR and HESWPME should also be immediately informed**
The trainee concerned will need extension of the training period e.g. ARCP outcome 3.
Trainees have a responsibility to engage with the educational process and are expected to follow guidance outlined by the GMC in Good Medical Practice as well as the curriculum requirements of their training programme. In addition to this, they have a contractual relationship with their employer and are therefore subject to local and national terms and conditions of employment.
Educators/Supervisors have a responsibility to supervise, guide and support trainees during their educational training programme, which includes identifying and addressing areas of concern and coming up with action plans moving forward (please see Appendix 1). They also have a responsibility to provide appropriate clinical learning opportunities.
The employer is responsible for ensuring that employment laws are upheld and employer responsibilities implemented. They are directly responsible for the management of performance and disciplinary matters and that issues identified are addressed in a proportionate, timely and objective way. GP training practices in Severn and Peninsula are considered to be employers, although the relevant PGME School of Primary Care will offer HR and other support for all performance and disciplinary matters concerning GP trainees.
HESWPME Professional Support and Well-Being Teams
The Professional Support and Well-Being Teams are responsible for identifying and offering appropriate additional support and resources for those who wish to access the service. Trainees can either self-refer or be referred by their supervisors to the service at the agreement of the trainee.
Following referral to Trainee Support, the first step is a meeting with a member of the team to explore the reasons for referral and to discuss the individual’s personal situation. From that, a package of support and development resources will be agreed which is tailored to individual need.
The relevant PGME Professional Support and Well-Being teams are advisory and do not supersede the assessment role of the Annual Review of Competency Progression (ARCP) Panel or employer’s Human Resources (HR) policies and procedures. We take guidance from national documents such as the GMC’s Good Medical Practice, the GMC’s Gold Guide, and guidelines issued by the UKFPO for Foundation Trainees (for further information, please see our Trainee Support Policy document).
Those participating in Annual Review of Competency Progression (ARCP) reviews of trainees are advised to recommend that a trainee who receives an adverse outcome makes contact with the Trainee Support Teams to see if we can help
Early Identification – Establishing the Facts
Early identification of issues and problems impacting upon a trainee’s progression is crucial. Most concerns can be addressed by early, effective discussions between the Clinical or Educational Supervisor and the trainee, culminating in a realistic learning plan which is regularly reviewed to monitor satisfactory progress.
An open and supportive culture should be encouraged within the whole clinical team, fostering the development of the trainee’s skills and providing constructive feedback on performance improvements or on-going concerns. Judgments should be avoided until all information/evidence is collected and considered. (NACT Guidelines, 2008).
**Issues of patient and person safety take precedence over all considerations in line with GMC guidelines**
Many factors can affect the performance of a doctor (Cox et al, 2006) and may occur individually or (more commonly) be interlinked. Concerns may be based on direct observable behaviours (such as lapses in concentration or poor clinical decision making). Such behaviours are symptoms rather than a diagnosis and as such, may be the tip of the iceberg, concealing a wide range of possible causes.
Difficulties tend to be attributed to the individual doctor, when their behaviour may be a result of problems within the team or even the wider work or home environment. Caution should therefore be exercised when determining what is going on.
Other factors that can indicate areas for concern include:
- Career uncertainty
- Emotional outbursts
- Low self-awareness
- Not engaging with educational processes
- For specific markers for GP trainees, see FAQ
Establish and clarify the facts (Adapted from the NHS Resulution (formerly NCAS) Performance Triangle):
In HESWPME, a matrix of trigger indicators with descriptors have been developed collaboratively to assist trainers in identifying and clarifying trainees’ problem, as well as promoting effective communication amongst trainers.
**Often it is not simply a matter of one clear issue, but rather a combination of overlapping issues*
Holding a support meeting and exploring the issues
This is the opportunity to explore with the trainee the issues and concerns by discussing any of the areas highlighted in the NHS Resolution (formerly NCAS) Performance Triangle (Clinical Knowledge and Skills, Health, Behaviour, Environment). Some issues may be sensitive and the trainee may not wish to discuss certain areas, additionally the trainee may not be ready to accept there is an issue. The Stages of Change model is a useful reference here to understand how individuals come to accept there is an issue and make steps towards positive change:
Source: Prochaska & DiClemente
Sufficient time should be allowed for this meeting so that neither the supervisor nor the trainee is rushed during this important initial discussion. For supervisors within general practice, initial discussions with the trainee should always be documented in the RCGP e-portfolio Educator Notes pages. If concerns persist, the local patch TPD/APD should be contacted at an early stage. They will co-ordinate subsequent formal support meetings as below.
Running the meeting
It is important to build rapport with the trainee and empathise with their situation – it is a big step for a trainee to open up about issues and they should be encouraged and supported along the way.
Giving feedback is crucial here so that the trainee is aware of exactly what the concerns are and why a meeting has been arranged. When running the meeting the following framework is useful:
- Introduce meeting and purpose
- Clarify confidentiality and time
- Identify and agree the issues with the individual
- Explore reasons for shortfall or difficulties with the trainee – perhaps there is more to the situation than initially presented
- Discuss and agree supportive and developmental actions (see ‘Developing an Action Plan’ in the next section)
- Document the session – keep this open and agree with the trainee
**Don’t forget to highlight and record areas of satisfactory performance**
Identifying resources for support
Clinical Knowledge and Skills:
Focused training or retraining may be appropriate here, including knowledge, technical skills, non-technical skills and professional skills. This may require an extended period of clinical supervision or targeted task oriented training focusing on a specific deficit.
Close supervision and dedicated ‘developmental monitoring’ can provide a supportive environment to tackle issues of insight into behaviour. Feedback from sources such as multisource feedback tools, video or simulation techniques can also be used to challenge behaviour. Further support in terms of psychometrics is available via the Trainee Support Teams.
Supervisors and educators should avoid acting as the trainee’s doctor. Whilst initial inquiries might be made into possible underlying physical or mental health issues, they should be referred to their employers Occupational Health or HR department for further guidance or assessment. GP practices can access OH services via the GP School.
GMC ‘Good Medical Practice’ requires doctors to seek and follow advice from a suitably qualified physician (OH) if their judgement or performance might be affected by a health condition. Referral to the trainee’s GP should also be considered. The Equality Act 2010 covers both mental and physical impairment that affect a person’s ability to carry out day-to-day tasks and requires employers to make reasonable adjustments to work pattern, content and environment.
Further support is available via the Severn and Peninsula Trainee Support teams.
Occupational Health can advise on suitable adjustments to the work environment (as above). Other work environment issues such as lack of resources, poorly maintained equipment and inadequate support should not be ignored. These may be issues that can be discussed with the Quality team in Peninsula PGME to see if a review of such issues needs to take place.
If the individual has a difficult home situation, considering a period of time off or a reduction in hours worked may be worth exploring (Less Than Full Time training). The PGME Trainee Support teams may be able to offer further support and resources in relation to this.
Developing an action plan
A useful template for developing an action plan has been provided by NHS Resolution (formerly NCAS). This framework suggests the following should be included in an action plan:
- Detail the areas of concern
- Outline possible interventions
- Identify the resources needed
- Identify potential support required
- Detail timeframes and schedule follow up review date
- Detail the sources of evidence/information needed to demonstrate progress
- If required - outline the implications for the trainee if the concerns are not addressed
(Adapted from NCAS ‘Back on Track’ framework – 3.2 Drafting an action plan).
The plan should be transparent and fully understood by the trainee. The trainee should be provided with a copy and a date for reviewing progress should be set. It may also be helpful for a copy of this action plan to be shared with the employers HR department or GP training practice (for GP trainees).
This meeting should take place at a time agreed between the supervisor and the trainee at the initial meeting.
The purpose of this meeting should be to review the trainee’s progress with the plan and to address any concerns or failures to achieve what was originally planned, considering any further support resources that could be helpful for the trainee.
Documenting the meeting is extremely important. Documentation should commence as soon as concerns come to light.
The local employers HR department should be consulted regarding the appropriate storage of this information. GP ES/TPDs should document initial concerns and any follow up action plans within the Educator Notes pages of the RCGP e-portfolio.
Guidance on documentation adapted from NHS Resolution (formerly NCAS) may be helpful: (a meeting template has been provided at the end of this guide to use during meetings).
Record good and poor performance
- Include enough information to guide an outsider
Make prompt file notes
- Stick to the facts
- Quote verbatim
- Include work information – personal information may be included on agreement with the trainee
- Record meeting details: length, venue, date and participants
- Be balanced
- Include trainee’s comments
It is important to consider who else the documentation should be shared with to ensure the on-going support of the trainee and patient safety. This can be discussed and decided with the trainee or HR or PGME can be contacted for clarification.
The following can help to ensure openness as well as rigour:
- Educators should avoid recording and keeping information about discussions with trainees without their knowledge or consent.
- Records of conversations should be held confidentially, with the trainee’s knowledge and consent, by the person who has conducted the assessment of the issues with the trainee.
- The trainee should be given a copy of any documentation concerning his or her performance and encouraged to keep such copies in his or her portfolio for discussion at appraisals.
- Should the trainee move to a different job, or in the event that the problem escalates or others become involved, it may become necessary to pass the record to other parties, again with the consent of the trainee where possible. Transfer of information about trainees’ progress from post to post should become standard procedure including areas of concern. E-portfolio can be a useful tool for recording the details of a trainee’s progress.
All documentation must comply with the requirements of the Data Protection Act and the Freedom of Information Act (FOIA). You should speak with your HR department regarding their information storage policy.
Accessing Further Support Resources
If the framework outlined in this guide has not addressed the issues or concerns regarding the trainee remain, it is appropriate to seek the advice and guidance from others such as the Programme Director, HR, Director of Medical Education or others in a senior education/supervisory role (Moderate Level).
The trainee’s employer HR department is crucial for helping to manage issues such as:
- Absence from work
- Continued health issues
- Short-term leave patterns
- Capacity issues
The trainee’s employer OH department are also an invaluable resource and can help with the following:
- Advising on the impact the trainee’s health may be having on their ability to work and conversely, on the effect work may be having on the trainee’s health.
- Liaising with treating practitioners to ensure a consistent and supportive approach to the trainee’s situation
If it is felt an Occupational Health referral would be beneficial, a referral can be made from either the trainee’s manager, Educational Supervisor or Programme Director direct to the trust OH department. A template for making an Occupational Health referral can be found in Appendix 4.
HESWPME Trainee Support Teams
If this does not help or if it is felt the situation requires specialist resources, the trainee can access the Professional Support and Well-Being Team for additional support (High Level). It is important that supervisors/educators remain central to the support of the trainee during this process.
- If there is any uncertainty about what to do next, others should be asked for guidance. Do not try to deal with complex scenarios alone! The Professional Support and Well-Being Teams are happy to be contacted for advice.
- Should the plan developed with the trainee fail to help the situation, or should the situation escalate into an issue regarding probity, fitness to practice or conduct, then the DME, HR and HESWPME should be notified.
Resources that the Professional Support and Well-Being teams can offer include:
- A meeting to discuss the issues raised in a supportive and confidential environment
- Confidential access to external counselling
- Access to and potential funding for specific training courses
- Referral to Occupational Health if a trainee is in between rotations a second opinion is required
- One-to-one confidential Careers Advice
- Access to dyslexia/dyspraxia/learning differences screening and assessment
- Access to language and advanced communication skills sessions
- Access to one-to-one psychometric development
- Confidential access to a support coach
- Short term funding for remedial supernumerary training in exceptional circumstances
- Advice for both trainers and trainees on issues regarding support
- In all circumstances where there are fitness to practice issues, the local trust HR and the PGME Trainee Support teams should be informed.
- Effective trainee support requires being clear about the criteria for success. These will be different for the Individual and for PGME and Employer. However, the overarching success criterion is a ‘return to safe practice’ and promoting the well-being of the trainee doctor.
- At all times it must be considered whether the trainee is safe to practice or not. If not, arrangements for their immediate removal from patient contact should be arranged and additional supervision and support provided. The Clinical Director and HR department should also be involved.
- Local employing trust/employer guidelines and policies should be followed when managing a performance/competence concerns. This will involve the employers HR department.
- Local employer policies should be followed regarding data storage and confidentiality of documentation and information collected when supporting a trainee.
Appendix 1 - Meeting template with action plan (Severn)
Appendix 2 - Trainee meeting Pro-forma (Peninsula)
Appendix 3 - PSU Coding Matrix
Appendix 4 - Referral form and guidelines
Appendix 5 - Occupational Health referral letter template
Appendix 6 - Trainee Support flowchart