It is vital that all possible steps are taken to identify and act on early signs of issues which may affect training progress. In most cases, issues are detectable at an early stage, which can prevent problems from escalating.
As a trainer, you play a key role in spotting potential issues with a resident/resident/trainee’s progression early. You can then help them put steps in place to prevent things from getting worse.
What can affect training?
A range of factors can affect a resident/resident/trainee’s progress. These rarely occur in isolation — a resident/trainee may experience several factors simultaneously, which can compound the impact on their training and wellbeing.
Predisposing factors
Previous ill health
Personal or family history of mental health difficulties
Prior adverse experiences in training
Precipitating factors
Acute events or significant life changes
Social isolation
Challenging or unsupportive working environment
Perpetuating factors
Chronic ill health
Ongoing organisational issues
Lack of access to appropriate support
Early identification will reduce the potential risks to the resident/trainee, patients, colleagues and to the organisation. Evidence suggests that good induction, properly constituted teams, and effective educational supervision reduce stress and potential challenges.
Signs to look out for
You might notice the following stress-related behaviours or performance indicators in a resident/trainee:
Behavioural and emotional signs
Avoidance or difficulty making decisions
Restlessness or appearing unsettled
Paralysed by perfectionism
Heightened or disproportionate reactions
Withdrawal from teaching or learning opportunities
Changes in engagement during supervision meetings
Seeking instant gratification or shortcuts
Discussing a career change
Health and lifestyle signs
Lower concentration or increased absenteeism
Frequent sick leave
Lifestyle impact, such as poor eating, poor sleep or withdrawing from personal life
Change in physical appearance
Professional and clinical signs
Failure to respond to bleeps or messages
Issues with timekeeping or personal organisation
Issues with record-keeping
Lack of insight or clinical judgement
Being unaware of their own limitations
Clinical errors
Failing assessments or examinations
Communication difficulties with patients, relatives, colleagues or staff
Workplace relationship signs
Being bullied or excluded
Difficulty with teamworking
Bullying, arrogance or rudeness towards others
Undermining colleagues, such as criticising or arguing in public or in front of patients
Act quickly and sensitively, balancing confidentiality and safety. If needed, ask colleagues for documented evidence. Ensure a positive, safe, learning environment - all colleagues should be supportive and non-judgmental.
When a concern arises, ask yourself:
‘Why this resident/trainee?’
‘Why here?’
‘Why now?’
Neurodivergence and Reasonable Adjustments
Some of the signs above may reflect an unrecognised or undisclosed neurodevelopmental condition, such as ADHD, dyslexia, dyspraxia or autism. It is important not to pathologise difference — neurodivergent residents/trainees often thrive with appropriate adjustments in place.
If you notice patterns that may suggest a neurodevelopmental profile, consider:
Having a sensitive, exploratory conversation with the resident/resident/trainee
Discussing whether a referral to occupational health or the PSU may be appropriate
Exploring whether reasonable adjustments under the Equality Act 2010 could be put in place
Signposting to the Access to Work scheme or a Reasonable Adjustment Passport
Do not wait for a formal diagnosis before offering support. If a resident/trainee discloses a condition, you have a duty to consider whether adjustments are reasonable and proportionate.
What to do if you spot these signs
Speak to the resident/trainee in a confidential setting and document the meeting.
Make the resident/trainee aware that concerns have been raised.
Listen to the resident/resident/trainee’s perspective and try to understand their experience.
Listen to others involved and seek insights from colleagues where appropriate.
Encourage commitment to change and a positive outlook.
Ask a colleague to join the meeting so you are not dealing with difficult situations alone.
Consider additional assessments, such as Multi-Source Feedback (MSF), to gather more information.
Complete the Educational Supervisor Report to update the resident/resident/trainee’s progression record.
Be mindful of differential attainment and whether protected characteristics under the Equality Act 2010 may be a contributing factor in the resident/resident/trainee’s experience.
Do not wait for the next Annual Review of Competence Progression (ARCP) to raise issues — there should be ‘no surprises’ at ARCP.
Contact the Professional Support Unit (PSU) for advice and support at any point.
Understanding the resident / resident/trainee
Providing the right support relies on understanding why a resident/trainee is struggling. Consider which of the following may apply:
Capacity
Physical or mental health challenges may be causing limitations. Consider whether a change to their role or job plan would help.
Learning
There may be gaps in skills or insufficient training and education. Offer skills-based education tailored to the resident/resident/trainee’s learning style and the available resources.
Motivation
A lack of motivation could stem from stress, boredom, bullying, burnout or an over-eagerness to please. Mentoring, counselling or addressing workload issues can help.
Distraction
External and workplace factors can significantly impact performance. Encourage the resident/trainee to seek professional help for issues outside of work.
Health
Both chronic and acute health problems can affect progress. A referral to occupational health or a visit to their GP may be needed. Single Lead Employer - Resident Hub
Alienation
If a resident/trainee has lost interest and commitment, this can sometimes be a response to systemic or cultural issues in the workplace and should be explored with care. Where alienation is leading to hostility or unsafe behaviour, the resident/trainee may need to be moved from the placement with appropriate support. Disciplinary measures may be required if patient or colleague safety is at risk.
Contact and Referral
If you decide to make a referral to the PSU on behalf of a resident/resident/trainee, please ensure you obtain their consent so we can engage with them effectively.
Residents/residents/trainees can also contact the PSU directly — a trainer referral is not required for self-referral. Learn more about what to expect from the PSU process after you submit a referral.
You can reach the PSU by:
Completing the online referral form on the HEIW website
Emailing: heiw.professionalsupport@wales.nhs.uk