Abstract
The Faculty of Intensive Care Medicine distributes an annual survey to its Consultants, allowing the evaluation of workforce profile, working patterns and the opportunity for analysis of key information on issues affecting these. We undertook an exploratory review of the data provided within the 2016 survey, with the aim of identifying themes within respondents stated career intentions and associated factors. Given the modest (36%) response rate, we are unable to draw conclusions with certainty, but there are indications within the data that the UK Intensive Care Medicine consultant body is facing significant stressors whilst at work, due to working patterns and limited resources. The data within the 2016 survey provide a base from which to develop future Faculty of Intensive Care Medicine workforce surveys that will extract data about the positive aspects of a career in intensive care medicine. The survey data provide a signal that there may be significant potentially modifiable stressors for intensive care doctors, and as such affords support for initiatives to improve job planning and sharing of implemented solutions, as well as a need to focus on workforce wellbeing as an important and necessary contributor to patient safety within intensive care medicine.
Introduction
Each year, the Faculty of Intensive Care Medicine (FICM) distributes a voluntary survey to Intensive Care Consultants in the UK via the FICM Fellows Database. The survey is designed to evaluate current workforce patterns, both at an individual and departmental level. Although the detailed content of the survey changes from year to year, some previous questions capture data on career intentions and general feedback regarding how participants view their current working life.
Within all healthcare systems there is increasing understanding and awareness of the impact of a career in healthcare on the individual, particularly in acute specialties such as critical care. 1 High levels of staff engagement and satisfaction impact positively on individuals, but also patient experience, safety, quality of care and organisational performance. 2 The first version of Guidelines for the Provision of Intensive Care Services (GPICS) did not specifically address standards or recommendations for workforce wellbeing. 3 Intensive care medicine (ICM) is a specialty tasked with delivery of high-quality patient care to the sickest patients, and dissatisfaction with working conditions, emotional exhaustion and even ‘burnout’ may therefore lead to negative consequences for both patients and staff. 4 Burnout has been described as a syndrome comprising ‘overwhelming exhaustion, feelings of cynicism and detachment from the job, a sense of ineffectiveness and a lack of accomplishment’. 5 It is these components that make burnout different from simply feeling exhausted due to the demands of the profession.
Historical data have previously identified symptoms of dissatisfaction, depression and emotional distress in intensive care physicians with >30% reporting symptoms of distress: significant stressors were bed and resource allocation, being over-stretched and the effect of hours of work and stress on personal/family life. 6
Using data from FICM workforce surveys our aims were:
To identify how FICM Consultants view their career in critical care medicine, with emphasis on job planning and typical working patterns as contributors, as these data were specifically sought in the surveys. To explore whether there was evidence of an intention to leave the practice of ICM early, or retire completely at an age earlier than the national retirement age. To investigate the presence of any associations within the data between working patterns and the free-text comments that may indicate the prevalence of consultant engagement or dissatisfaction with their role. To undertake an exploratory screening of the free-text responses for any indication of emotional exhaustion, or positive responses related to personal accomplishment (as described within burnout screening tools).
Methods
Data capture took place between February and July 2016 by the FICM secretariat, via an emailed link to the online survey to consultant members of the FICM fellows database (participants were informed about data storage and use in line with the Data Protection Act (1998)). For our review, an agreement regarding data storage was written in accordance with advice from the FICM Caldicott Guardian. We obtained a copy of the 2014, 2015 and 2016 survey data: the 2016 survey can be seen in online Appendix 1. The 2017 survey was excluded, as the nature of data capture during that year was a mini-census, with very little qualitative data available for analysis.
This analysis focuses on the 2016 data, however, where corresponding questions across the surveys were identical we compared the data across all three years.
Data were provided in a Microsoft Excel Worksheet and analysed both within this software and PRISM (Graph Pad Software). Data were anonymised prior to analysis by the removal of location (hospital, trust and deanery) and individual identifiers. Basic demographics regarding the individual’s workplace and current working patterns (including number of non-job planned hours spent on the ICU per week, how many weekends and nights they were contracted to work) were obtained from quantitative data, where respondents had completed pre-filled text options.
Qualitative data in the form of free-text responses were coded and analysed to try and elicit themes which make a career in critical care medicine attractive, and to investigate career factors hypothetically leading to dissatisfaction.
We extracted quantitative data about the age at which respondents intended to stop practicing ICM. Qualitative data regarding working patterns and career intentions (such as reasons for re-attendance, plans for changing levels of ICM commitment) were coded according to themes identified in free text and investigated accordingly.
Data were explored to identify the presence of any potential associations between career intentions and contributory factors, as well as the relationship between current age and the age consultants stated an intention to stop ICM. Two markers of current work intensity were selected: ‘Number of nights per week spent on ICU’ and ‘Number of non-job planned hours spent on ICU’ and analysed against two markers of potential workforce dissatisfaction: ‘Do you intend to work in ICM for the remainder of your career’ and ‘What age do you anticipate stopping ICM’. Data were analysed using two-way ANOVA within contingency tables.
Free text comments were reviewed for any indications of personal accomplishment or emotional exhaustion (as defined within the Maslach Burnout Inventory (MBI) 7 ). Only statements that corresponded with exact wording in the MBI were counted in the analysis.
Results
Number of respondents registered to each clinical subspecialty.
Free text answer.
Seventy-three (78%) units were General Adult Critical Care, eight (9%) were Cardiac, seven (8%) neurocritical care and five (5%) Burns Critical Care. Clinical leads were asked several questions regarding the nature and level of staffing within their unit. In the General Critical Care Units, 81% had a dedicated trainee on the unit 24/7, 14% had a dedicated staff grade doctor and 5% had a dedicated advanced critical care practitioner (ACCP) or equivalent.
Baseline values regarding current working patterns can be seen in Figure 1. There were some anomalies with data entry, which may reflect the differences between weekly and annual job planning. Within the General Critical Care units, 1% of respondents were contractually required to be resident 24/7 and 29% stated that they currently had consultant posts with ICM clinical PAs unfilled. A total of 360 respondents (46%) stated the frequency of returning to hospital when on call was rare, with 274 (36%) returning every other on call, and 74 (9%) returning during every on call. After coding and grouping free-text responses, the most commonly cited reasons for this were overwhelming clinical workload (306, 23%), a complex clinical case (289, 21%) and to support junior trainees (274, 20%). Other reasons for re-attendance are listed in Table 2.
Histograms illustrating basic working patterns within Intensive Care Medicine. Reasons cited for returning to ICU during an on-call (combined annual and weekly job plans).
The modal response for the age respondents anticipated stopping ICM was within the range 56–60 years of age (338 (44.7%)). The distribution of responses is illustrated in Figure 2. A significant association was seen between the current age of the respondent and the age they anticipate stopping ICM (p = <0.00001), with the largest proportion of those between 41 and 55, all anticipating stopping ICM between 56 and 60 or even earlier (Figure 3). Two hundred and ninety-four respondents stated they did not intend practicing ICM for the rest of their career. Pre-defined reasons for this were cited 960 times, with 236 (25%) stating ‘work life balance’ and 233 (24%) citing ‘frequency of on call, stress or work intensity’ as their main reasons for this intention.
Age at which respondent stated they anticipated permanently stopping critical care medicine. Distribution of age respondents anticipated permanently stopping critical care medicine, grouped according to their current age.
A total of 126 (17%) stated that they would like to decrease their ICM commitment over the next two years. Reduction in out of hours’ commitment and moving into a different specialty or non-clinical role were the most alluded to contributory themes (21% and 20% respectively). A total of 394 (51%) respondents stated they found ICM significantly stressful enough to influence their future career plans. A total of 420 suggestions were provided in response to the question ‘What could be changed to reduce this effect?’ The most common themes were ‘Increase trainee numbers’ (86 (20%), ‘Increase number of available beds’ 83 (20%) and ‘Change in rota pattern/Reduce OOH’ (82, (20%)). ‘Improved team working’ – reflecting the working dynamic between different specialties within the hospital was cited 52 (12%) times.
‘Work-life balance’ and ‘frequency of on-call, stress and work intensity’ were the top two reasons selected from a list of pre-defined values for not intending to continue ICM for the remainder of a respondent’s career across all three survey years. The absolute proportions of these reasons being mentioned were similar (22%, 23% and 24% for work life balance, and 22%, 25% and 24% for frequency of on call stress and work intensity across 2014, 2015 and 2016, respectively). The main change between 2014 and 2016, however, was the absolute number of times these reasons were cited, which was the greatest in 2016.
Far more positive than negative responses for retaining an interest in ICM were obtained, but those expressing that their intention to practice ICM for the remainder of their career decreased across the three years from 77% in 2014 to 61% in 2016. The proportion of those stating that ICM was stressful enough to alter future career plans increased across the three years (from 47% in 2014 to 52% in 2016). Respondents wanting to increase their commitment to ICM in 2016 were 10% down from 14% in the previous two years. Those wanting to decrease their commitment were up to 17% in 2016 from 14% and 12% in 2014 and 2015, respectively.
There was no significant association between the number of nights per week spent on ICU and the intention to work in ICM for the remainder of the respondent’s career or the age at which the respondent anticipated stopping ICM. It appeared that there may be a significant association between the number of non-job planned hours spent on ICU each week and the age at which the respondent anticipated stopping ICM, reaching statistical significance for both increasing age (p ≤ 0.0001) and increasing hours spent on ICU (p = 0.0117). An increasing number of non-job planned hours spent on ICU also appeared to correlate significantly with the age anticipated stopping ICM (p = 0.0098 and p ≤ 0.0001 for each value, respectively).
Nine domains of burnout related to emotional exhaustion (as defined by the Maslach Burnout Inventory) which were found within free-text responses.
Discussion
This project provides an exploratory review of how a career in critical medicine is viewed by a significant number of senior individuals working within it. It is noteworthy that unlike the 2018 planned workforce census, previous censuses have not asked respondents for positive factors that impact on their working conditions nor have the questions been designed with a specific focus on workforce satisfaction. Any interpretation of the free-text comments and association between current working patterns and self-reported intention to leave ICM is therefore made with considerable caution, as the survey was not specifically designed to capture this information. There were some significant inconsistencies within the data itself, particularly when reporting the number of nights and weekends consultants were expected to work during the year, which suggests that making direct linkage between these data and workforce satisfaction is difficult. This may in part be due to the structure of previous surveys which did not easily allow for individual job plan calculations, in addition to misinterpretation by respondents as to whether they were reporting weekly or annual commitments.
This may explain some of the anomalies in the reported workforce patterns – for example, respondents may be covering anaesthesia as well as ICM services whilst on call, which would potentially explain the low weekend on-call frequency reported by some, and which might result in intensely stressful on call periods even though infrequent. As such, whilst we have explored associations among the data, such associations should be interpreted with caution.
For data protection reasons, we did not analyse data according to the location of the respondent, and consequently did not correlate responses and intentions to regions, staffing levels or unit structure.
Arguably, the achievement of a substantive consultant post in critical care medicine may be (and perhaps should be) viewed as a ‘job for life’; however, there is limited research into how a career spent within any acute medical specialty can influence this original intention. Literature from multiple specialties and countries suggest links between work intensity, job satisfaction and opportunities for job progression as being associated with intention to leave any medical specialty 8 ; however, it is less clear whether this translates to leaving the career early. A recent survey across 23 German ICUs demonstrated a significant relationship between the perception of giving non-beneficial treatment and increased intention to leave. 9 In contrast, there is a larger body of literature regarding nursing staff and their career intentions, with contributory factors to leaving early being poor working conditions and clinical competence. 10
Intention to leave and intention to stay do not measure the same construct, particularly when considered in the context of job satisfaction and these surveys did not interrogate any factors associated with a positive work experience in ICM. 11 It is conceivable that there is a significant body of positive feeling towards a career in ICM which has not been elicited by this survey.
Thus, in future work, there is scope to explore further the reasons for intention to leave critical care medicine by exploring personal and work-related characteristics and linking these to job planning and opportunities for further career development and progression within and outside ICM, e.g. in research or management.
Nevertheless, there is evidence within the 2016 FICM workforce survey of an increasing expressed desire to leave either ICM or clinical medicine earlier than current retirement age, or at the very least, reduce critical care clinical commitment. Our analysis also suggests that younger consultants articulate a desire to retire from ICM at an earlier age, in contrast to those who have been working in the specialty for longer. One reason for this may be the transition from training to a consultant role which is a recognised stressor for medical staff. 12 This may suggest a greater role for the development of mentoring and coaching to provide support throughout a career in ICM, an intervention which has been shown to be beneficial to the mentee, mentor and even the wider organization. 13
We elicited several themes within the data that provided information about what was making a career in ICM appear unattractive in the longer term. The 2016 survey appears to demonstrate dissatisfaction with a lack of work–life balance, level of out of hours commitment, and increasing requirements to support junior staff (both due to a lack of numbers and perceived reduction in clinical skills) and ongoing issues with bed capacity. This was consistent with that seen in previous surveys.
There was some indication that there may be elements of burnout present within the workforce, particularly within the domain of emotional exhaustion, although we cannot quantify this; as such, it may be that FICM can try to improve this by addressing job planning and unit staffing. This observation corresponds with other reviews into burnout within healthcare workers, 14 which often utilise self-reported data, but our analysis demonstrates at best a suggestion of burnout within a self-selected group of respondents. The 2018 FICM workforce census will examine both positive and negative aspects of working in ICM to gauge a more balanced view of identified stressors and supports within the job. The FICM is also focussing on developing tools to assist people to pursue a lifelong career in ICM through its ‘Recruitment to Retirement’ strategy. We speculate that identification of emotional exhaustion may be a wider problem within the ICU workforce and is an area that can be targeted for future investigation, possibly by use of a quality improvement approach to staff support and engagement as suggested by the Institute for Healthcare Improvement. 2
There are limitations of the 2016 FICM Workforce Survey and our analysis of it. The response rate for this survey is modest, at approximately 36%, whilst low, this is consistent with published response rates for similar surveys – without the use of incentives, response rates for physician completed surveys are notoriously low. 15 The response rate and survey design create three potential problems. Firstly, our sample may not be representative of the entire critical care consultant workforce. Secondly, there may be a negative bias present within the responses, in terms of those who elected to complete the survey are also those who are dissatisfied with their current working conditions. Finally, and perhaps most significantly, the phrasing of the questions favoured identification of problems within the working environment, rather than encouragement to report positive elements regarding a career in ICM.
Conclusion
Our exploration of the data within the 2016 FICM survey has indicated that there is a signal present within the data suggesting dissatisfaction with a career in ICM amongst some elements of the UK ICM medical workforce. However, this analysis does not provide any indication of how significant this signal is, given the modest (and potentially biased) sample size. Self-reported symptoms of stress are consistent with a previously published survey of the UK workforce 6 and suggest that the focus on improving patient care and treatment in ICM has not addressed workforce wellbeing sufficiently in recognition of its significant contributory role to patient safety. The Critical Futures report produced by the Faculty 16 has emphasised this and version 2 of GPICS will specifically consider standards for ensuring the mental and physical health of the workforce.
The 2018 FICM workforce census has been designed with the assistance of a psychologist and with the intention of identifying both positive and negative factors in a properly representative way. Future evaluation will therefore enable a more detailed analysis of these factors and link them to job planning and would also explore positive constructs such as intention to stay within ICM, and the reasons contributing to this. This may provide data which can be used in the development of strategies for promotion of a career in ICM and tools to implement change at a local and national level.
Supplemental Material
Appendix -Supplemental material for The Faculty of Intensive Care Medicine Workforce Survey – What impacts on our working lives?
Supplemental material, Appendix for The Faculty of Intensive Care Medicine Workforce Survey – What impacts on our working lives? by KE Grailey, DC Bryden and SJ Brett in Journal of the Intensive Care Society
Footnotes
Acknowledgements
We would like to thank Dr Jack Parry-Jones, FICM Workforce Lead for his work in the construction and analysis of previous survey data and his review of an early draft of the manuscript. We would also like to thank the staff of the FICM and the FICM Workforce Planning and Recruitment Committee; for their support in accessing and analysing the data.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
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