Returning to clinical training after maternity leave
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5965 (Published 09 October 2013) Cite this as: BMJ 2013;347:f5965
- Alexandra Brightwell, specialist registrar, paediatrics1,
- Susie Minson, specialist trainee, paediatrics2,
- Allison Ward, specialist registrar, paediatrics2,
- Caroline Fertleman, training programme director, London School of Paediatrics2
- alex.brightwell{at}doctors.org.uk
Abstract
Doctors increasingly take maternity leave during training, but little is known about the challenges they face in doing so. Alexandra Brightwell and colleagues held focus groups to try to fill that gap in evidence and to learn about the issues faced by trainees taking maternity leave
Professional women face a variety of challenges during maternity leave and when they return to work. A perceived loss of competence, feeling unsupported by colleagues and seniors, and a lack of confidence in being up to date can reduce the chances of a successful transition back to work.
These difficulties affect women doctors as much as other professional women; by 2017, women are expected to make up the majority of doctors practising in the United Kingdom.1 Doctors are increasingly taking time out of work for maternity leave, and given the timing of postgraduate training, maternity leave is likely to be the most common reason that a doctor will take time out of training.
To help mitigate the difficulties women face when returning to work after maternity leave, UK employers are encouraged to offer up to 10 “keeping in touch days” to all employees on maternity leave.2 This time is paid and is arranged on an individual basis, but it is not compulsory for either employee or employer.
To help support doctors returning from time out of clinical practice, including after maternity leave, the Academy of Medical Royal Colleges published guidance in 2012 on returning to practice.3
Little evidence exists on how and when doctors’ competence is lost after a period of absence from work. However, there is strong evidence linking how often skills are refreshed and updated with attrition of skills in specific areas, such as advanced life support.4 Loss of competency is also thought to be related to how well knowledge and skills were learnt and practised before the period of absence from work.5
The fact that skills attrition may be related to how well skills were acquired before absence from work is of particular relevance to trainees taking maternity leave. Many doctors who are in training when they take maternity leave may have two or three periods of absence in relatively quick succession. They may also have had only relatively limited experience and exposure to particular areas before taking time out.
There is little evidence describing the experiences and concerns of doctors returning from maternity leave and the type of support they may require. We therefore examined the experiences of postgraduate trainees who had recently taken maternity leave, to explore their concerns and anxieties. We conducted a series of focus groups with current paediatric trainees who were either on maternity leave or who had recently returned to work after maternity leave (box 1). Transcripts of the groups’ discussions identified the main issues that concern trainees preparing to return to training after maternity leave.
Box 1: Focus groups
All paediatric trainees on maternity leave within a single large deanery (about 1000 trainees in paediatrics, of whom two thirds are women) were invited to attend a free return from maternity leave study day. Trainees on maternity leave were identified from deanery records. Topics covered during the course included hot topics in paediatrics, simulation scenario practice, and networking.
All trainees who registered for the course were invited to participate in the focus groups. Invitations were sent in advance of the course and trainees were under no obligation to participate.
A total of 65 trainees were identified as being on maternity leave and were invited to participate in a one day “return to practice” course. From this group, 22 trainees attended the course, and all participated in the focus groups, which were conducted in groups of seven or eight with one facilitator.
The focus groups were recorded, and each focus group lasted 30-45 minutes. The trainees all gave written consent to participate in the focus groups and for the use of anonymised verbatim quotes in research. Full ethical approval was obtained.
A modified framework analysis was used to analyse the written transcripts produced from the audio recordings of the focus groups.6 The transcripts were read, re-read, and rated independently by AB, SM, and AW. Any potentially identifying material was removed from the transcripts, and none of the raters had access to the identity of the doctors.
Emerging themes were identified from the transcripts and further refined by the framework analytic approach. This is based on a grounded theory method of data analysis, where themes are derived from the data.7 This is a systematic approach that allows a full and comprehensive review of the data collected and the themes generated from the original accounts of the participants. We checked that there was agreement within the research team that particular themes and categories had not been over-represented or under-represented. The transcripts were repeatedly reviewed until all raters agreed that no new themes were emerging. The transcripts were individually coded by hand once agreement between the three researchers involved in analysis was achieved.
This method meant that our study was limited to the experience of a small group of trainees from one specialty and deanery, all of whom were motivated to attend a return to work training course. There are also a number of recognised limitations of focus groups, and we recognise that focus group research is less powerful than when multiple methods of inquiry are used. It is clear that further research in this area with doctors from a range of specialties and levels of seniority is needed to understand these issues better.
Attrition of skills
The trainees universally identified attrition of knowledge and practical skills as one of their major concerns about returning to training. They believed that they had lost skills and knowledge while they were away from practice and were concerned that their confidence had fallen. One participant said, “I don’t feel that I have the same confidence in my own ability and limitations that I had previously, and I find that scary.”
Trainees thought that they may have missed new developments in their field during their time away and would not be up to date with current practice. One said, “I’m worried that so much will have changed. I had planned to keep up to date with journals while I was away, but with a small baby to look after there just wasn’t time.”
Despite the validity of the trainees’ concerns about knowledge and skills attrition, it was clear that there was little support and planning in place for their return. Most trainees in our focus groups had done some reading or preparation for their return to work.
Several had attended resuscitation courses, but such courses had to be self funded at a time when trainees were usually on maternity pay. One participant said, “I just did the APLS [advanced paediatric life support] course last week—I had to pay for it myself as I had no access to study funding on maternity leave, but I really needed to increase my confidence and decided it would be money well spent.”
Going straight back in
Almost all participants expressed concern about being expected to resume clinical work at the same level as before their maternity leave. Many believed that there would be no acknowledgment that they had been away from clinical work for a considerable time. One trainee said, “I worry that people won’t realise how out of my depth I am feeling when I go back, and you know you don’t want to be shouting it out that you’re rubbish, but equally you don’t want to be unsafe.”
Participants also worried about being expected to work out of hours without direct supervision from their first week back. One commented, “I’m especially worried as I start back on nights as the registrar and I’ll be covering A&E [accident and emergency] and neonates—I really don’t feel ready to do that straight away, but I don’t want to be seen as lazy or not pulling my weight so I’ve just agreed to do it.”
Most said they would be going straight back to full duties from the first day—on one occasion to cover night shifts at a new place of work—despite evidence supporting the benefits of a supported return to practice.8 Keeping in touch days were not used by our group, many of whom were unaware of the scheme or were unable to arrange such a day as they would be returning to work in a trust different from the one where they had previously worked.
Anecdotal evidence from other specialties suggests that there is poor awareness of keeping in touch days among both consultants and doctors in training. Despite acknowledgment from the National Patient Safety Agency that doctors returning from maternity leave may need further training,8 there was no evidence from our focus groups that trainees could access this before returning to work.
The Academy of Medical Royal Colleges is clear that planning for a return to work after a career break should begin before the break from practice begins. In the case of maternity leave, this should begin during pregnancy.
We believe that courses specifically aimed at trainees returning from maternity leave, such as our one day course in paediatrics and those offered by other specialties,9 should be offered to all trainees. In addition, specialty specific, easily accessible knowledge updates should be made available, such as the Essential Knowledge Updates e-learning course provided by the Royal College of General Practitioners.10 Crucially, mentoring and peer support of trainees by doctors with experience or trained in supporting trainees at times of transition should be offered, in addition to usual clinical and educational supervision.
Logistical worries
Leaving small children to return to work is difficult for all parents, but the trainees in our focus groups identified some concerns specific to clinical training. Many expressed anxieties and difficulties around arranging childcare. Most had been told which hospital they would be working at only three months before their return date, and many did not have their individual timetable until just before they started work, most of which include fixed annual leave. One trainee said, “I’ve really struggled to arrange childcare—I’m going back as a flexi-trainee, but I only found out which three days I’ll be working three weeks before I start back, and of course you can’t book a nursery place or nanny without knowing what days you want. So I’ve ended up having to pay for a full time nursery place for the first two months just so that I can be covered.”
Several participants said they would be returning to work while breast feeding their baby. None expected that they would be able to successfully combine breast feeding with work. One commented, “I assumed that by the time I went back to work I’d have stopped breast feeding, but here we are and I’m about to go back to work . . . I guess it will have to be cold turkey.” Another said, “The whole idea that you could express [breast milk] while on call is frankly ridiculous.”
Training less than full time
Many trainees opted to train less than full time after maternity leave and were keen to make it work for them. However, for those with no previous experience of less than full time training, there was frustration at the lack of easily accessible support and guidance, particularly from within their department, as to how to go about organising and making this work. One said that less than full time training “seems so confusing.” She said, “I have been given such conflicting information about what I’m expected to do etc and I’m not really sure who to ask.”
A particular concern among trainees in our focus groups was how they would be perceived by their seniors and peers. The trainees believed that, as working parents, they would have split responsibilities, and they worried about how this would affect them professionally. One participant said, “I need to leave by 17:45 at the very latest, but I don’t want to leave extra work for my colleagues or to be the trainee that everyone thinks is a bit rubbish.” Another commented, “I’m anxious about what would happen when my child is sick—I’ve worked with colleagues before who were [negatively perceived] because they took time off to care for their child.”
Working with sick children
Many of the participants in our focus groups expressed concern about working with very sick children. They thought that this would be much harder now that they were parents themselves and didn’t think that there would be support in learning to cope with this. One trainee said, “I’m terrified of being in a situation where I see a child the same age as mine in [a resuscitation unit] and just being completely overwhelmed.” Another commented, “I worry hugely about seeing sick children now that I have my own—it seems completely different and I don’t feel I’m equipped to cope.”
Our trainees were also concerned about the emotional impact of looking after sick children. This may affect trainees in paediatrics disproportionately, but trainees in many specialties, such as emergency medicine, general practice, and surgery, will be exposed to sick children.
Despite all these concerns, the participants expressed strong beliefs that they would be better doctors as a result of their experiences of parenthood and were highly motivated about their careers (box 2).
Box 2: Positive aspects
The major themes that emerged from our focus groups were concentrated on trainees’ anxieties and concerns. But the participants also identified positive aspects of returning to clinical training. Many looked forward to going back to work and positively anticipated the professional and social interactions that clinical work entails. One said, “I’m looking forward to having some time with colleagues and to using my brain again. I’ve been a doctor for much longer than I’ve been a mum, and it will be nice to have that part of my identity again.”
A number of trainees believed that becoming parents themselves would make them better paediatricians—that they had more sympathy and understanding for the families that they look after. One participant said, “I feel differently about how I’ll practise—I hope it makes me a better paediatrician. Being away from work with other parents makes me realise how special our job is.”
Footnotes
We thank the trainees who participated in the focus groups for sharing their views and experiences.
Competing interests: We have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.