Abstract
The UK’s National Health Service (NHS) is probably in the midst of its biggest crisis since its foundation in 1948 (Unite, 2013). The principal reasons are the cumulative effects of public spending austerity, accelerating market reforms, systemic failures in care and health provision (Francis 2013; Keogh, 2013) (e.g. accident and emergency cover) and an ageing population. The deleterious impact on the 1.4 million NHS staff is widely reported in the media with news stories on a range of employment issues: unsustainable working hours and patient-loads (BMA, 2014); chronic understaffing, including failures to recruit and retain staff (Clark, 2014); unhealthy and unsafe working conditions (Carpenter, 2014), including bullying and abuse of staff (Timm, 2014); deteriorating real pay; and record numbers of clinicians leaving to work in other countries. The cumulative effect is deteriorating health and social care (Care Quality Commission, 2014). For a labour intensive, specialist service like the NHS, the question of employment sustainability is of central strategic importance, especially for highly trained clinical staff (Iacobucci, 2013). The current estimated shortfall of clinical staff is 20,000 (Daily Telegraph, 2014) and set to rise further (Imison and Bohmer, 2013; RCN, 2011).
Studies of the NHS clinical labour process have commonly been of nurses emotional labour (Theodosius, 2008), general practitioners and hospital doctors working hours (MacBride-Stewart, 2013); nurse and junior doctor burnout, stress and job dissatisfaction (Farquharsen et al., 2012; Perry, 2014); work-life balance for professional women and gender inequality (Crompton and Lyonette, 2010); work rationalisation, intensification (Cooke 2006; Smith et al, 2008), extensification (Clark, 2014) and poor clinical staffing levels/workloads in relation to forecasting future requirements (Ball et al, 2012). Furthermore, studies from outside of the UK reveal similar findings (e.g. Solberg et al. 2012; McGowan et al., 2013), suggesting common features to clinical employment across developed economies. While this literature addresses issues related directly to long-term job sustainability amongst clinicians, to date there has not been a study that focuses on early-career clinicians changing expectations of working in the NHS from the latter stages of professional training through to their formative experiences as NHS employees, during the initial years as qualified practitioners.
This paper reports the initial findings from a pilot study of 20+ (data collection is on-going) early career NHS nurses and junior doctors at a variety of stages of professional development ranging from the latter years of Nursing/Medical School through to their initial three years as a qualified NHS clinician. Semi-structured, in-depth interviews lasting between 60—90 minutes were undertaken with all participants. Each was asked to reflect on their knowledge and expectations of working conditions and career in the NHS while in training and to contrast that with their actual experience as employees in hospitals, including their current expectations and future career plans.
Our findings reveal that while there is less of a gap between the initial expectations of nurses and the reality of their working conditions when compared to trainee doctors, the training for both professions leaves them unprepared for the impact of unmanageable workloads, endemic long-hours, chronic fatigue and unsocial shift working. This is particularly pronounced amongst junior doctors. Consequently, many early career clinicians quickly reassess their professional - and vocational - aspirations by revising long-term career plans to prioritise bearable, personally sustainable, working conditions, including improved work-life balance, frequently deciding against the extra harsh demands of hospital working and emergency/acute medicine. Thus, crucial early-career decisions are too often primarily based on avoiding unsustainable working and employment conditions, which may mean leaving the NHS, rather than pursuing the most appropriate long-term clinical career direction. As NHS working conditions continue to deteriorate as a consequence of austerity-driven underfunding, the likelihood is that early-career clinicians will increasingly opt for long-term coping-survival career strategies, further exacerbating the long-term crisis of under-staffing and declining care quality.
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