Insight report resource
NHS Resolution’s Practitioner Performance Advice service has found that 70% of cases discussed with us by employers/contracting organisations have an element of concern relating to behaviour and/or conduct of the doctor, dentist or pharmacist who is the subject of the request for advice (see our July 2022 Insights paper). These behaviours can impact on team dynamics and potentially on patient safety.
One of the interventions we can offer to support the resolution of such concerns is a behavioural assessment. This specialist intervention provides an independent view on the behavioural characteristics of the practitioner, including any areas which require consideration, and gives the employing/contracting organisation information to help decision-making about the next steps in their management of the case. This intervention is formative in nature and designed to support the practitioner’s professional development.
The occupational psychologists we work with at Edgecumbe and Work Psychology Group have analysed the findings in the 141 assessments of doctors undertaken between 2013 and 2019. We confined the study to doctors as they were the majority of the behavioural assessments carried out and there was an existing control group of doctors for comparison. The psychologists undertook both a qualitative review of a number of reports and a quantitative analysis of the psychometric tests completed by the doctors participating in the assessment process.
This Insights paper presents the findings of our in-depth study, and will be of particular interest to medical directors, senior clinical managers, HR professionals and practitioners to better understand the key themes emerging from our behavioural assessments. The analysis also aims to help employers and practitioners to reflect on when a behavioural assessment delivered by the Practitioner Performance Advice service can assist with the resolution of behavioural concerns where they arise.
Findings
Four overlapping themes emerged from the qualitative analysis and these are presented combined with summaries of the relevant psychometric findings associated with each theme. The psychometrics of the doctors who underwent a behavioural assessment were compared to those of a control group of doctors who were not the subject of concerns. This control group was provided from other data held by the psychologists.
The overarching theme was a lack of self-awareness and insight. Associated with this were issues with impaired resilience, problems with interpersonal relationships and their approach to managing operational challenges. The following graphic shows these themes together with a number of areas identified relating to each theme.
Looking at each theme in slightly more depth, we also summarise in the graphics some of the psychometric findings which were seen more or less often in the doctors assessed than in the control group. It is important to note that, although there were significant differences, the individual characteristics seen in the psychometric analysis should not be used as a diagnostic and are only part of the whole picture.
Lack of self-awareness and insight
This theme cut across all the others. Doctors described developing themselves, but this tended to focus on clinical and technical skills and knowledge, and not personal growth and interpersonal skills.
Their narrative indicated a lack of self-awareness around the limits of their knowledge and competence, the impact of their behaviour on others, and areas for personal development. Many of the doctors failed to show that they sought or accepted feedback. They also tended to attribute blame externally, and had not sought to deal with concerns prior to their referral to Practitioner Performance Advice.
Impaired resilience
This theme covered three areas: demands on the doctor, lack of support and irritability.
Many of the doctors had experienced considerable demands in the period preceding their referral to Practitioner Performance Advice. These appeared to have taken the doctors’ time, energy and focus away from their work, potentially contributing to the reasons for their referral. These demands included personal or family health issues, heavy workloads and the high standards expected of the doctors.
Some lacked the support needed to cope with demands because they:
- Lacked the self-awareness to realise they needed support
- Denied personal vulnerabilities and exercised self-control over their behaviours to manage others’ perceptions of them
- Did not recognise that it is their personal responsibility to seek support when they needed it
- Withdrew from others, in turn reducing the likelihood of others recognising their need and offering support
Some doctors appeared to be prone to becoming privately but easily irritated and frustrated by others. Under pressure some seemed to lack sufficient self-regulation and coping strategies, resulting in outbursts and being perceived as angry or irritable.
In this group ‘leisurely’ meant they were overtly cooperative but privately irritable, stubborn and un-cooperative.
Problems with interpersonal relationships
Many of the doctors appeared to be introverted, transactional and functionally focused with limited interest in connecting with others socially outside of the necessary interactions and communication needed to ‘get the job done’. In some this may have been exacerbated by lack of trust in others’ intentions or motives.
Most of the doctors communicated in a frank and direct manner. Whilst their communication approach might be considered to be clear, many described being perceived as lacking in diplomacy, blunt, rude, inconsiderate and insensitive.
In contrast, a cohort seemed highly motivated to maintain good relationships but displayed low levels of assertiveness. This group were more likely to avoid conflict, disliked providing negative feedback, and struggled to convey their messages clearly.
Operational challenges
This theme related to doctors reporting frustration about the impact of administrative and/or clinical guidelines on their work and decision making. They often disagreed with these and found them unnecessary. Some said that they were more likely to bend them to suit them or their patients’ needs. This approach was more common in highly self-confident doctors who displayed low levels of self-awareness of the limits of their competence. It also came from doctors who felt guidelines impeded compassionate responses to patients and described situations relating to moral injury or distress.
Most of the doctors’ profiles showed them as highly patient-centric, compassionate and motivated to put patients’ best interests first. They were similarly compassionate to the control group. Sometimes this appeared to cloud their judgement and adversely impact on their ability to balance empathy and objectivity in decision making, setting boundaries and interactions with patients and colleagues.
Many displayed a preference to control the environments they work in, favouring those which are familiar and present low levels of ambiguity and risk. Their profiles described their preferences for building routine, stability and predictability into their lives with the consequence that when under more pressure than usual they could be inflexible or reluctant to delegate.
Methodology
There was a quantitative analysis of the psychometric findings from 141 reports. The psychometrics used in the assessments were the Revised NEO Personality Inventory (NEO PI-R) and the Hogan Development Survey (HDS). This analysis attempted to answer the question ‘What are the factors common in practitioners referred to Practitioner Performance Advice?’ Comparison was made with a control group of doctors at consultant level applying for substantive roles in the NHS and who were not the subject of concerns.
The NEO PI-R assesses five dimensions of personality, each with six subcategories. The HDS measures 11 derailing tendencies that can impede career success and interpersonal effectiveness.
Overall, the analysis of the psychometrics showed significant differences across most domains of both tests when compared to the control group. A random sample of 30 reports was selected for thematic analysis. A priori power analysis confirmed that these two samples were appropriate to determine a medium effect size. However, firm conclusions should not be drawn based on psychometric test scores alone and they do not provide indication of causality. The differences from the control group are indicated above in the detail for each theme.
Demographics
The demographics of the doctors assessed are shown below. There are some differences from the characteristics of all practitioners referred to us (see our July 2022 Insights paper) although these cannot be considered conclusive due to the relatively small numbers.
The main differences are:
- Primary care predominates
- White doctors were more commonly assessed than other ethnicities
- Those who qualified outside of the UK or EEA were less commonly assessed
Other observations
The psychologists were also able to make some observations on the impact of the referral to Practitioner Performance Advice and the assessment process on practitioners.
On the positive side, the referral and ensuing process was often well received with:
- Many of the practitioners approaching it proactively and constructively, seeing it as an opportunity for them to ‘clear their names’ and continue in/return to practice
- Many expressed the intent to minimise the opportunity for, and the impact of, the characteristics that caused adverse consequences for themselves and for others going forward
- In some cases the referral/process in itself appeared to prompt retrospective demonstrations of capacity for insight, development and change
- Many engaged in self-reflection, CPD activities and personal development to address the concerns raised
Conversely, others found the process induced feelings of remorse, regret and shame, which impacted their wellbeing and capacity to practice effectively. The analysis also reported:
- Increased self-consciousness and reduced self-confidence in their ability to practice/make independent decisions
- Over-cautiousness, including over-reliance on others for support and gaining consensus
- Scepticism, paranoia and withdrawal from others to avoid scrutiny
This may indicate the need to identify and offer increased support for practitioners who are the subject of behavioural concerns and to emphasise the formative and supportive nature of the process.
Our Assessment and Remediation team are working to continuously review and improve our assessments. This also includes an evaluation of the online delivery of behavioural assessments which was introduced during the Covid-19 pandemic; this involves seeking feedback from both referrers and practitioners. They are also considering the findings of this analysis and working with colleagues to see if additional tools can be found to help identify issues earlier and more specifically, and whether any new and appropriate ways can be found to resolve issues earlier.
Since this analysis we have introduced the Motives, Values, Preferences Inventory (MVPI) as an additional psychometric; this looks at the individual’s core goals, values, drivers and interests. We are also piloting the use of Professional Dilemmas. These are psychometric tests designed to assess judgement in work-relevant situations. They focus on professional attributes, such as integrity, empathy, resilience and team working. We have developed a bespoke set of Professional Dilemmas for use in the context of our behavioural assessments.
Finally, we would like to thank all at Edgecumbe and Work Psychology Group for undertaking both the assessments and this analysis.
Our Insights publications share analysis and research which draw on our in-depth experience, providing expert, impartial advice and interventions to healthcare organisations. By sharing these insights, we aim to support the healthcare system to better understand, manage and resolve concerns about doctors, dentists or pharmacists. You can find all past reports on our Insights webpage.
If you are interested in hearing more about our research and Insights programme, please get in touch with us at Practitioner Performance Advice:
nhsr.adviceresearchandevaluation@nhs.net
If you’d like to learn more about our work and the services we offer, please visit our dedicated Practitioner Performance Advice webpages. Our Education service offers training courses to provide healthcare organisations with the knowledge and skills to identify and manage performance concerns locally.
You may find our Behavioural assessments video helpful. This explains what a behavioural assessment involves, and the types of situations in which it can help to achieve resolution where a concern has arisen about an individual practitioner’s behaviour.
Download Behavioural Assessments: findings from an in-depth qualitative and quantitative analysis
