Constraints and affordances for UK doctors‐in‐training to exercise agency: A dialogical analysis

Abstract

IntroductionThe goal of medical education is to develop clinicians who have sufficient agency (capacity to act) to practise effectively in clinical workplaces and to learn from work throughout their careers. Little research has focused on experiences of organisational structures and the role of these in constraining or affording agency. The aim of this study was to identify priorities for organisational change, by identifying and analysing key moments of agency described by doctors‐in‐training.MethodsThis was a secondary qualitative analysis of data from a large national mixed methods research programme, which examined the work and wellbeing of UK doctors‐in‐training. Using a dialogical approach, we identified 56 key moments of agency within the transcripts of 22 semi‐structured interviews with doctors based across the UK in their first year after graduation. By analysing action within the key moments from a sociocultural theoretical perspective, we identified tangible changes that healthcare organisations can make to afford agency.ResultsWhen talking about team working, participants gave specific descriptions of agency (or lack thereof) and used adversarial metaphors, but when talking about the wider healthcare system, their dialogue was disengaged and they appeared resigned to having no agency to shape the agenda. Organisational changes that could afford greater agency to doctors‐in‐training were improving induction, smoothing peaks and troughs of responsibility and providing a means of timely feedback on patient care.ConclusionsOur findings identified some organisational changes needed for doctors‐in‐training to practise effectively and learn from work. The findings also highlight a need to improve workplace‐based team dynamics and empower trainees to influence policy. By targeting change, healthcare organisations can better support doctors‐in‐training, which will ultimately benefit patients.

We the system: A call for a perspective shift towards systems agency in trainees

“…In their paper 'Constraints and affordances for UK doctors-in-training to exercise agency: a dialogical analysis', Mattick et al call for urgent work to enhance agency for doctors-in-training. 1 Agency can be understood as trainees' ability to act independently within the system and make decisions about their educational trajectory, professional development and patient care. 2 As a trainee impacted by COVID-19, the challenges of learning to navigate agency were exacerbated by a system under strain.…”

“…3 Mattick et al call for 'urgent work […] to provide medical trainees with greater agency and favourable workplaces'. 1 The authors highlight learners feeling 'disengaged [and] resigned' and their 'perceived powerlessness to influence a wider agenda'. 1 Addressing trainees' perceived lack of agency to change the system is crucial.…”

“…1 The authors highlight learners feeling 'disengaged [and] resigned' and their 'perceived powerlessness to influence a wider agenda'. 1 Addressing trainees' perceived lack of agency to change the system is crucial. Maximising systems agency will mitigate disengagement and leverage changes that trainees are uniquely positioned to make.…”

“…2,6,7 Mattick et al suggest that learners' perceived lack of agency can arise from a shift away from the patient as the object of the activity towards systems-level issues. 1 If learners also perceive agency primarily as the ability to influence their personal trajectory, learners may therefore perceive the shift from individual to systems issues as a lack of agency. Agency may be better interpreted as directed at activities spanning clinical care, research and learning, bridging the gap between the individual and the system.…”

“…A shift towards agency as expressed through clinical care, research and learning expands opportunity for trainees to find agency within a 'faceless nameless entity'. 1 Mattick et al call for ways for trainees to 'influence the wider policy agenda' to combat perceived powerlessness when systems-level issues overshadow individual patient care. 1 They suggest 'amplify[ing] existing positive affordances of agency; for example, when doctors-in-training collaborate positively with peers, and suggest process improvement'.…”