Guidance and support for trainers

Why early intervention is important

Early identification of issues with progression can prevent escalation to a more serious situation.

Trainees' performance can be impacted for various reasons:

• predisposing factors e.g. previous ill health, personal issues
• precipitating factors e.g. acute events, social isolation
• perpetuating factors e.g. chronic ill health, organisational issues.

Early intervention will reduce the potential risks to the trainee, to colleagues, patients and also the organisation. There is evidence to suggest that good induction, properly constituted teams, together with effective educational supervision reduces stress and potential challenges.

Signs and triggers

You might recognise these stress behaviours:

• avoidance, finding it hard to make decisions for example
• restlessness
• paralysed by perfection
• lower concentration
• arrogance / overconfidence
• heightened reactions
• lifestyle impact - poor eating habits; not sleeping; “missing out” on life
• instant gratifications.

What next?

Act quickly but sensitively, balancing confidentiality and safety:

• to take immediate action once aware of concerns
• ask for documented evidence from relevant colleagues and team members
• speak to the trainee and document the meeting
• consider appropriate assessments to gain information e.g. Multi-Source Feedback (MSF)
• feedback is very important; the trainee must be aware that issues have been raised
• do not deal with difficult scenarios on your own; ask a colleague to attend the meeting with you
• educational supervisor report is vital for informing progression of trainee
• do not wait for the next annual review to raise issues - 'no surprises' at annual review (RITA / ARCP)
• feel free to contact the Professional Support Unit (PSU) for support at any point.

Underlying reasons and explanations

Successful support for trainees requires an accurate understanding of the underlying reasons for the difficulty, in order to tailor subsequent intervention to the individual's circumstances, personality, abilities or learning style (e.g. McManus et al, 2004). Ask yourself:

• why is it happening to this trainee
• why now
• why in this situation.

There may be any number of reasons.

Capacity - a fundamental limitation that will prevent them from being able to do their job (e.g. mental or physical impairment). If so, then change of role or job may need to be considered.

Learning - a skills deficit through lack of training or education. In these cases, skills-based education is likely to be appropriate, provided it is tailored as closely as possible to the individual learning style of the doctor and is realistic within existing resources.

Motivation - a drop in motivation through being stressed, bored, bullied or overloaded - or being over motivated, unable to say no, anxious to please, etc. In these cases some form of mentoring, counselling or other form of support may be appropriate and/or addressing organisational issues like workload, team dysfunction or other environmental difficulties that may be affecting motivation.

Distraction - something happening outside work to distract the doctor; or a distraction within the work environment (noise or disruption; team dysfunction). The doctor may need to be encouraged to seek outside professional help if the problem is outside work.

Health - an acute or chronic health problem which may in turn affect capacity, learning or motivation. Occupational Health may have a role here; or the doctor may need to be encouraged to visit his or her GP.

Alienation - a complete loss of any motivation, interest of commitment to medicine or the organisation, leading to passive or active hostility, "sabotage" etc. This cannot generally be rectified and damage can be caused to others (patients and colleagues) and to the organisation if allowed to continue for too long. The doctor should be moved out of the organisation, with whatever support or disciplinary measures may be deemed appropriate.

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