TE18 Policy for Assisting Trainees in Difficulty

AUSTRALIAN AND NEW ZEALAND COLLEGE OF ANAESTHETISTS
ABN  82 055 042 852

POLICY FOR ASSISTING TRAINEES IN DIFFICULTY - 2010

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1. OVERVIEW

1.1 Trainees can experience difficulty during their training for many reasons. This policy seeks to assist Supervisors of Training and Heads of Department when supporting Trainees at these times, by helping in the identification and resolution of these difficulties. This can be extremely challenging, but ultimately very rewarding (1). The processes described are intended to support Trainees. They are not to be a disciplinary measure (which is a matter for Medical Boards or Councils).

1.2 Other relevant College Professional Documents are: TE5 Policy on Supervisors of Training in Anaesthesia (2), TE14 Policy for the In-training Assessment (ITA) Process (3) and TE19 Policy on Trainee Illness and Disability (4).

1.3 Professional and personal development during training requires that Trainees:

1.3.1 Contribute to the work of their training department.

1.3.2 Reach work-related performance standards (appropriate to their stage of training) (3).

1.3.3 Progress towards necessary levels of responsibility and autonomy.

1.3.4 Meet other training requirements, such as successful completion of examinations.

1.4 Trainees in difficulty are those who are not making sufficient progress in training or who are experiencing difficulties with certain elements of their training. The difficulties encountered may include, but are not limited to, any one or a combination of the following:

1.4.1 Clinical performance below that expected for the stage of training.

1.4.2  Personal problems, illness and/or disability which interferes (temporarily or permanently) with training and/or performance of duties.

1.4.3 Failure to pass College examinations.

1.4.4 Personality traits or other issues which impair professional communication or teamwork.

1.4.5 Substance abuse* or dependence involving opioids, alcohol and/or other drugs.

*NB: Suspected opioid substance abuse requires a specific investigation and management process outside the scope of this document. See Welfare of Anaesthetists SIG Resource Document 12, Suspected or Proven Substance Abuse and the associated document The Substance Use Protocol (9). Professional advice should be sought and compliance with the regulations of the Medical Board of Australia or the Medical Council of New Zealand is necessary.

2.  CONCERNS ABOUT TRAINEE PERFORMANCE: IDENTIFYING TRAINEES IN DIFFICULTY

2.1 Identifying Trainees in difficulty, whose workplace performance is affected or those whose performance or progress is below the standard expected for their stage of training, is an essential role for everyone involved with the Training Program. In all situations, the welfare of patients as well as the Trainee must be carefully considered.

2.2 Staff members with concerns about any aspect of a Trainee’s performance must discuss their concerns promptly with the Supervisor of Training and Head of Department. The Supervisor of Training and/or Head of Department should take steps to address such concerns by making specific, confidential enquiries about the perceived issues and gathering information from relevant staff members as well as the Trainee to establish the truth about the concerns expressed. At times, Trainees may self-report that they are having difficulty. (See the College website (5) for a diagnostic ‘triage approach’ to identifying problems and some suggested strategies). Patient safety and Trainee welfare are paramount (See Section 5).

2.3 It should be determined whether the problem is one of conduct (employment or jurisdiction) or training. Employment issues should be managed by the Head of Department in consultation with the employer’s Human Resources Department.

2.4 The ITA Process (3), which assesses Trainee performance across a number of domains, from a number of sources, is a useful framework to assist in determining the nature of the problem.

2.5 Unless the issues are serious (that is, threaten patient safety, or represent professional misconduct, see Section 5), the approach for training issues is one of a staged response, of interview, offers of support, remedial strategies to improve performance and ongoing monitoring (3).

2.6 Assistance may be sought from the Regional or National Education Officer (REO/NEO) and/or the Training & Assessments Unit at the College in Melbourne.

3. TRIGGERS FOR FURTHER ACTION

3.1 The TE18 Process should be implemented when:

3.1.1 Trainees consistently perform at a level which is considered to be below that acceptable for a developing specialist anaesthetist, that is below the level expected for their stage of training (‘no’ on the ITA-Form global assessment).

3.1.2 Trainees perform at a level which is considered borderline for a developing specialist anaesthetist (i.e. ‘borderline’ for the level expected for their stage of training on the ITA-Form global assessment) on two successive End-of-Term Assessments.
 
3.1.3 Trainee performance between End-of-Term Assessments in the ITA Process raises concerns which are considered to need immediate attention.

4. DOCUMENTATION

4.1 The Supervisor of Training and/or the Head of Department must maintain adequate permanent records of discussions with the Trainee (5). The records should include the date of the discussion, the matters raised and the views expressed by the Trainee. Any information provided that there may be disciplinary action must be clearly stated. Such information must be understood and acknowledged in writing by the Trainee. A failure to accept or acknowledge a warning would be grounds for initiating a disciplinary process (see sections 2.3 and 5.1).

4.2 It is advisable to seek assistance from the relevant hospital Human Resources Department to ensure compliance with employment legislation.

5. SERIOUS ISSUES: PROFESSIONAL MISCONDUCT OR A RISK TO PATIENT SAFETY

5.1 Disciplinary action in respect of employment or medical registration is a matter for the employer or the relevant Medical Board or Council (6, 7) if there is evidence of serious breaches of care. Mandatory reporting exists in some jurisdictions. In some situations (e.g. evidence of opioid misuse), it may be appropriate (or required) for the Head of Department to report the matter to the relevant Medical Board or Council. Additional assistance and support may be available through these bodies. Any disciplinary action (especially dismissal) requires due process to be followed.

6. PROCESSES TO BE FOLLOWED WHEN IT IS CONFIRMED THAT A TRAINEE IS IN DIFFICULTY

6.1 The procedures below should be followed, with a further review of the Trainee’s performance after an agreed period. The objective is to overcome difficulties in a supportive, holistic and collaborative manner within a specified timeframe.

6.2 The principles of natural justice (8) must be observed. These include that the Trainee must be formally notified of all steps being taken.

6.3 The Head of Department should follow the requirements and process prescribed by the local regulatory/registering boards for doctors. The Welfare of Anaesthetists SIG resource documents may be a useful adjunct to the process (9).

6.4 Initial Steps

6.4.1 The Head of Department should be informed that an Interview has been scheduled. The initial interview with the Trainee, led by the Supervisor of Training, should include the following:

6.4.1.1 A formal time should be set aside for the discussion with sufficient advance warning for the Trainee.
6.4.1.2 The Trainee should be offered the opportunity to bring a support person.
6.4.1.3 Shortcomings in performance/progress should be clearly identified.
6.4.1.4 The Trainee should provide a self assessment, having the opportunity to provide an explanation about the difficulty they are experiencing (this may identify issues which will facilitate offering support in the most appropriate way).
6.4.1.5 Clear expectations on required performance/progress should be outlined.
6.4.1.6 Agreed, achievable goals together with practical suggestions for their attainment and an outline of any suitable, available resources should be set.
6.4.1.7 An agreed definite time frame for improvement should be determined.
6.4.1.8 Assistance and resources available to assist the Trainee should be identified and offered.
6.4.1.9 An agreed definite time frame for the Trainee to access such assistance and resources should be determined.
6.4.1.10 An action plan including follow up meeting dates should be documented.

6.4.2 The Supervisor of Training should inform the Head of Department of the outcome of the meeting and document the discussion on the Remedial Interview Record (5).

6.5 Remedial Learning

6.5.1 The Supervisor of Training and/or the Head of Department should organise individualised learning experiences if appropriate to assist with difficulties with examination preparation or presentation technique, acquisition of clinical skills or interpersonal skills development. The Trainee has a responsibility to actively participate in these activities.

6.6 Advice and Counselling

6.6.1 The Supervisor of Training and/or Head of Department must ensure that appropriate advice is available. Early constructive advice may be pivotal to Trainees’ professional development.

6.6.2 It is important also for Trainees to have appropriate personal and professional support. If they do not already have one, Trainees should be strongly encouraged to select a mentor to provide advice, feedback and support. The Supervisor of Training or the Head of Department should discuss mentorship and the choice of the mentor with the Trainee. The Trainee is free to select his or her own mentor, although some assistance may be appropriate if the Trainee is having difficulty in identifying a suitable person. A mentor should have no formal involvement with the Trainee’s appointment or reappointment, or with assessment.

6.6.3 It is possible that all Trainees will need help on occasion. Some examples of individuals from whom Trainees may seek advice include:

6.6.3.1 A mentor, as above.   
6.6.3.2 A senior member of the Department.
6.6.3.3 The REO / NEO.
6.6.3.4 A member of the Welfare of Anaesthetists SIG.

6.6.4 Assistance from the above should be limited to advice and support. Treatment, if required, should be from relevant qualified practitioners in a therapeutic (and not a supervisory or mentor) relationship with the Trainee.

6.6.5 In some situations, the Trainee must be advised to seek professional assessment and management. The Trainee should be assisted to find an appropriate person when he/she requests it. On occasion, prompt medical or psychological intervention may be essential. Relevant professional assistance may be sought from:

6.6.5.1 The Trainee’s general practitioner. 
6.6.5.2 A medical specialist appropriately qualified for the Trainee’s medical condition, for example, a psychiatrist or an occupational health physician.
6.6.5.3 A psychologist.

6.6.6 Not withstanding the above, additional professional support may be obtained from:

6.6.6.1 Pastoral care services
6.6.6.2 Relationship counseling services
6.6.6.3 The Doctor’s Health Advisory Service
6.6.6.4 A drug and alcohol service
6.6.6.5 A career advice service or counselor.

6.7 Monitoring Progress

6.7.1 The progress of the Trainee following the institution of any procedure referred to in this document must be monitored at regular, prospectively determined times. Progress monitoring may supplement the formal In-Training Assessment (ITA) Process (3).

6.7.2 It is expected that the majority of Trainees will respond positively to the above measures.

7. UNSATISFACTORY PROGRESS

7.1 Advice on any Trainee’s performance may be sought from the Regional/National Education Officer and/or the Training & Assessment Unit at the College in Melbourne.

7.2  If a satisfactory resolution cannot be achieved using the provisions of this document, further assessment may be undertaken using the Trainee Performance Review process (10).

7.3 The Supervisor of Training must record the processes followed and any meetings that take place as outlined in Section 6 (4).

REFERENCES

1. The London Deanery Faculty Development (n.d.) Managing the trainee in difficulty [online]. Available: http://www.faculty.londondeanery.ac.uk/e-learning/managing-poor-performance

2. Professional Document TE5 Policy for Supervisors of Training in Anaesthesia 

3. Professional Document TE14 Policy for the In-Training Assessment (ITA) Process

4. Professional Document TE19 Policy on Trainee Illness or Disability

5. For copies of templates, forms and other documents that support the process, see the College website www.anzca.edu.au

6. Medical Board of Australia (n.d.) [online] Available: http://www.medicalboard.gov.au/

7. Medical Council of New Zealand (n.d.) [online] Available: http://www.mcnz.org.nz/
8. Principles of natural justice: www.ag.gov.au/www/agd/agd.nsf/Page/Securityvetting_Whataretheprinciplesofnaturaljustice and www.justice.govt.nz/publications/global-publications/t/the-guidelines-on-the-new-zealand-bill-of-rights-act-1990-a-guide-to-the-rights-and-freedoms-in-the-bill-of-rights-act-for-the-public-sector/publication (sections 27.1 – 27.3)

9. The Welfare of Anaesthetists Special Interest Group Resource Documents contain information about a number of the issues noted in this document and are available on the College website (www.anzca.edu.au).

10. Trainee Performance Review, Regulation 33: www.anzca.edu.au/resources/regulations/regulation-33.html
11. ANZCA Privacy Policy
12. ANZCA Training Agreement: www.anzca.edu.au/trainees/trainee-forms/training-agreement

ANZCA professional documents

College Professional Documents are progressively being coded as follows:

TE Training and Educational

EX Examinations

PS Professional Standards

T Technical

POLICY–defined as ‘a course of action adopted and pursued by the College’.These are matters coming within the authority and control of the College.

RECOMMENDATIONS–defined as ‘advisable courses of action’.

GUIDELINES–defined as ‘a document offering advice’.These may be clinical (in which case they will eventually be evidence-based), or non-clinical.

STATEMENTS–defined as ‘a communication setting out information’.

This document has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this document in each case.

Professional documents are reviewed from time to time, and it is the responsibility of the practitioner to ensure that the practitioner has obtained the current version.Professional documents have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently.

Whilst the College endeavours to ensure that professional documents are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently.

Promulgated:  2000
Reviewed:  2005, 2010
Date of current document:   June 2010*

*This Professional Document is being piloted for 12 months and will be reviewed in June 2011.

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ANZCA Website: http://www.anzca.edu.au/