DOI: 10.1111/tog.

12652 2020;22:147–54
The Obstetrician & Gynaecologist
Education
http://onlinetog.org

The key features of highly effective training units in

obstetrics and gynaecology
Marie O’Sullivan MRCOG,
a,b
* Sarah Newell MRCOG,
c
Jonathan Frost MRCOG,
d
Joanna Mountfield FRCOG
e,f

a
ST7 Obstetrics and Gynaecology Trainee, St Michael’s Hospital, Bristol BS2 8EG, UK
b
Vice Chair (Education), National Royal College of Obstetricians and Gynaecologists Trainees’ Committee, Royal College of Obstetricians and
Gynaecologists, London SE1 1SZ, UK
c
ST6 Obstetrics and Gynaecology Trainee, St Michael’s Hospital, Bristol BS2 8EG, UK
d
Gynaecological Oncology Subspeciality Registrar, Cheltenham General Hospital, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham
GL53 7AN, UK
e
Consultant Obstetrician and Director of Education and Workforce, University Hospital Southampton, Southampton SO16 6YD, UK
f
Vice President for Workforce and Professionalism, Royal College of Obstetricians and Gynaecologists, London SE1 1SZ, UK
*Correspondence: Marie O’Sullivan. Email: marie.osullivan@doctors.org.uk

Accepted on 21 May 2019.

Key content  Learning from excellence may be more helpful than focusing on
 High-quality training environments may increase job satisfaction, negative aspects of poor training.
reduce attrition and promote excellence in education and training.
Learning objectives
 Data on training are collected through the General Medical
 To understand the fundamental features of highly
Council Survey, Training Evaluation Form and Workforce Survey.
 Attrition rates in obstetrics and gynaecology are high (30%) –
performing units.
 To identify contributors to poor training performance.
among the highest across all specialties – and reasons for this  To implement a simple structure for analysing
include morale and undermining, training processes and
training performance.
paperwork, support and supervision, work–life balance, National  To learn simple interventions that can improve training.
Health Service environment and job satisfaction.
 High attrition rates affect the remaining workforce and can have a Keywords: education / learning environment / training
negative impact on the working environment.

Please cite this paper as: O’Sullivan M, Newell S, Frost J, Mountfield J. The key features of highly effective training units in obstetrics and gynaecology.
The Obstetrician & Gynaecologist 2020;22:147–54. https://doi.org/10.1111/tog.12652

be the first people who notice negative behaviours that have

Introduction
Promoting excellence in medical education and training is
essential to developing high-quality doctors for the future,
especially in times of increasingly complex patients and high
trainee attrition.1 It is also imperative to acknowledge that
the learning and clinical environments cannot be separated:
patients are safer when the learning environment is better.2 It
is also likely to be the case that, when patients are safe and the
learning environment in which to train is safe, learning will
be improved. Trainees within poor, unsupportive learning
environments or trainees exposed to bullying and
undermining may not perform well and be more likely to
leave the profession. Junior doctors who are subjected to or
who witness bullying and undermining make more mistakes,
are less effective in teams and are less likely to voice
their concerns over patient safety issues. The experience
of trainees can be a useful insight into the values and
leadership within a unit, as being new to a unit, trainees may
become normalised.3,4
The medical learning environment is unusual in terms of
education, given its multidimensional construct and the
constant potential for conflict between duties that trainees
feel are high-intensity training opportunities (such as in the
elective gynaecology theatre) and duties that they feel are
focused on day-to-day patient care (such as ward cover) or
administrative tasks (sometimes called ‘service provision’).5
Of course, the distinction is always blurred, as often all
activities have a training and learning benefit. However, it is
the mix of activities and the ability to learn and develop skills
that is important. In addition, attrition rates for UK
obstetrics and gynaecology (O&G) trainees are at an all-
time high, at around one-third (29–37%),1 and are among
the highest across all specialties. The Royal College of
Obstetricians and Gynaecologists (RCOG) Trainee Attrition
Survey (2017) demonstrated that 75% of O&G trainees had
seriously considered leaving the specialty, with 89% feeling

ª 2020 Royal College of Obstetricians and Gynaecologists 147

 Effective training units
low in mood, depressed or anxious, and 19% stating that they
felt this way at least on a monthly basis.1 Recent high-profile
cases surrounding trainee involvement in adverse medical
incidents have led to more trainees questioning their career
choices, with some considering such cases to be a step
backwards for patient safety and the ‘blame-free’ learning
culture.6 In addition, the debate over junior doctor contracts
and the associated industrial action have had a lasting impact
on the morale of the junior workforce.7 While there is no
clear evidence that low attrition is directly related to effective
training, they are likely to be closely connected. Not all
trainees will leave the training programme as a result of
negative experiences. However, the work undertaken by the
RCOG on attrition has identified features, such as workload
and stress, which are also likely to impact negatively on
trainees’ experiences of training and education, and which
undoubtedly increase attrition rates.
In the clinical arena, there has been a change in focus from
learning by reviewing negative events and outcomes to
learning from excellence. Positive reporting strategies have
been shown to improve a positive working culture, which in
itself has been associated with improved patient outcomes.8
The same use of positive reporting and learning from units
assessed as excellent may be beneficial in medical education
and training. With trainee attrition and training evaluation,
traditionally the focus has been on identifying areas of bad
practice, where improvement is needed.9 In 2017, the RCOG
Training Evaluation Committee (TEC) shifted the focus to
the lessons that can be learnt from the highly performing
units, asking educators at these units to provide feedback and
insight into how they create effective learning environment. It
was considered important to reward excellence in these units,
as well as to investigate the ways in which they provided
high-quality training.
National feedback on O&G training is regularly collected
via the General Medical Council (GMC) Survey, the RCOG
Training Evaluation Form (TEF) and the RCOG Trainee
Attrition and Workforce Survey. These have identified the
key reasons for trainee attrition as low morale and
undermining, training processes and paperwork, support
and supervision, work–life balance, NHS environment and
job satisfaction.1,9,10 A recent study assessing factors that may
reduce trainee attrition identified the following key themes:
being valued as an individual, flexibility and predictability,
standardisation and transparency in processes to promote
fairness, access to quality support, and learning-focused
training.9 Reducing attrition in units and retaining a well-
functioning workforce may improve the training
and environment.
In 2015, the Joint Royal College of Physicians Training
Board (JRCPTB) published quality criteria for core medical
training, designed to enhance the educational experience of
core medical trainees.11 Following this, in 2016, the three
148
Royal Colleges of Physicians of the UK published quality
criteria for higher levels of medical training, setting an
educational vision for assisting doctors in training and
maximising the educational value of high-demand
service needs.12
Using the JRCPTB domains,12 existing literature, national
guidance, the Gold Guide and a national analysis of the TEF
results,4,11–18 this article proposes a checklist of quality
criteria that training units can use to benchmark their
education and training against the best units in the country,
and identify ways to improve the learning environment
within their units (Appendix S1). These quality criteria have
been derived by members of the TEC and approved by the
RCOG Education Board to support the new RCOG core
curriculum. The authors suggest ways that training units can
improve their learning environment and trainee satisfaction.
Trainees are also responsible for training – their own and that
of others – and it is hoped that this article will also help
trainees to improve culture in their own units.
It is important to be aware that many of the difficulties
faced in O&G currently do not solely affect trainees; rota gaps
and attrition are also prevalent at consultant level, adding a
further layer of complexity to providing excellent patient care
and ongoing training. The ability to influence culture and
raise standards is everyone’s responsibility, and working
together will be the key. The GMC’s National training surveys
2018: initial findings report highlighted the stark realities of
training and being trained in the current frontline
medical workforce:19
 Nearly one-quarter of doctors in training and just over
one-fifth of trainers are burnt out.
 Almost one-third of trainees said that they are often or
always exhausted at the thought of another shift. Around
half of trainees and trainers reported that they often or
always feel worn out at the end of their working day.
 One-fifth of trainees and trainers feel short of sleep when
at work.
 Two in five trainees and two-thirds of trainers rated the
intensity of their work as very heavy or heavy, and nearly
half of all trainees work beyond their rostered hours on a
weekly or daily basis.
 One-third of trainees and trainers reported that training
opportunities are lost due to rota gaps
Top tips from the best units
Following a review of the TEF data, four national awards
were given to the highest-ranking units across the following
domains (from 171 units):
 Overall performance
 Obstetric training
 Gynaecology training
 Professional development.
ª 2020 Royal College of Obstetricians and Gynaecologists
 O’Sullivan et al.

Box 1. Summary of responses from the educators at the units

where trainees had given the best RCOG Training Evaluation Form
scores in 2017 and 2018 when asked, ‘What makes you
particularly proud with regard to training and education within
your unit?’

2017 responses
“This is important for me to know that our patients are getting great
TEF top 10 units 2017 care from satisfied doctors and these great doctors want to come back
as consultants to work with us.”
TEF top 10 units 2018
“We have focused on creating an ethos based on support and training,
and a ’culture change’. Our quality panel data was excellent in all areas,
as well as excellent in all areas for our foundation programme. We have
an exchange programme that has seen our last exchange trainee for
New Zealand coming back for a post-Certificate of Completion of
Training job, and our last ST7 also stay for a benign gynaecology
fellowship.”

“The rota is done by me as college tutor along with a rota admin

person. I make sure the trainees are allocated to the appropriate lists
and clinics according to their need. It makes a huge difference to their
training. Nobody is allowed to pull the trainees out of their training to
provide service commitment.”

“All our consultant body in Antrim Area Hospital are very

approachable, respect and appreciate the hard work that the trainees
undertake in order to run a safe efficient service.”

“We are delighted that the trainees in Lanarkshire value the effort and
dedication of all staff in the Trust who help them achieve their personal
training goals, and that they have given us such positive feedback.”

2017
Antrim
Ulster
NHS Borders
Southend University NHS Foundation Trust
NHS Lanarkshire
Royal Devon & Exeter NHS Foundation Trust
South Tees Hospitals NHS Foundation Trust
Worthing & Southlands Hospitals NHS Trust
Craigavon Area
Peterborough & Stamford Hospitals NHS Foundation Trust
2018
Southend University NHS Foundation Trust
Peterborough & Stamford Hospitals NHS Foundation Trust
Dartford & Gravesham NHS Trust
Lancashire Teaching Hospitals NHS Foundation Trust
Western Health & Social Care Trust
Northern Health & Social Care Trust
NHS Lanarkshire
NHS Borders
Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust
Poole Hospital NHS Foundation Trust
Figure 1. Map showing the best performing units based on 2017/18
Training Evaluation Form (TEF) data.
The top ten performing units for 2017 and 2018 can be
seen in Figure 1.18
The next top nine units in each domain were ‘highly
commended’, and feedback was sought from all of the top ten
2018 responses
“. . . A functional team – treating medical students, junior medical staff
and registrars as team members and equals.”
“Continuity to ensure continuous progression of trainees during their
time in the unit.”
“Turning service provision into training opportunities.”
“Increasing opportunities for team training and simulation.”
“[We have] at least maintained our strong reputation for 2 years in a
row. We have all put in a lot of work over the last 8–9 years or so. . .and
have successfully ‘turned around’ a unit that was having problems a
few years ago.”
units. They were asked: ‘What makes you particularly proud
with regard to training and education within your unit?’ and,
‘If you could pick three top tips for success to share with
other units, what would these be?’ The responses received are
summarised in boxes 1 and 2.
The same educators were also asked, ‘what could you do to
improve education and training even more?’. Box 3 shows
the responses from the educators at the best units in 2017
and 2018.
Trainees complete the GMC Training Survey every year,
and the results from the TEF are cross-referenced to ensure
that units score consistently in the subsequent survey. The
overall winner in 2017 was Antrim, and in 2018 it was
Southend University NHS Foundation Trust.

ª 2020 Royal College of Obstetricians and Gynaecologists 149

 Effective training units
Box 2. Summary of responses from the educators at the units
where trainees had given the best RCOG Training Evaluation Form
scores in 2017 and 2018 when asked, ‘If you could pick three top
tips for success to share with other units, what would these be?’
2017 responses
“Respect and acknowledge the hard work trainees undertake in your
unit.”
“Equally respect and acknowledge the contribution of all staff who are
involved in training. In good units, this is everyone: doctors, nurses,
midwives and allied health professionals.”
“Design your rota with a focus on meeting the trainee’s needs.”
“Take an interest in, encourage and guide individual trainees
depending on their skill set.”
“Good units have consultants with lead roles, such as college tutors,
with paid time in their job plans for education. Use of Supporting
Professional Activity time for education is encouraged and promoted as
being equally as important as other lead roles, such as risk
[management].”
“Encourage hands-on consultant supervision.”
“Be approachable and open to feedback as a consultant team.”
“Take every opportunity to teach – be innovative.”
“Develop a meaningful induction.”
2018 responses
“Trainee-centred unit.”
“Focus on pastoral care so trainees feel valued and supported.”
“Value and respect trainees."
“Open-door policy so that trainees feel able to discuss anything with
consultants.”
“Team structure.”
“Team effort – everyone has to be 100% committed to teaching and
training.”
“Have lunch together – it’s about being part of a team.”
“Divide work up as evenly as possible – this could mean a consultant
covering a less interesting session to ensure that a trainee gets to
theatre.”
“Matching educational supervision and clinical supervision with the
education and career aims of trainees.”
“Have a committed rota coordination team led by a consultant who
has trainees’ learning needs at heart.”
“Develop an educational faculty.”
Of the top ten units, only four were commended in both
2017 and 2018. However, it is difficult to draw conclusions
on consistency of excellence based on just 2 years’ worth of
data; trusts may merge in between surveys, or have no
trainees in a survey year. Trainees usually rotate on a
6-monthly or annual basis, and therefore further longitudinal
data is required to assess whether units are truly good or bad,
rather than simply happening to have a particularly positive
150
Box 3. Summary of responses from the educators at the units
where trainees had given the best RCOG Training Evaluation Form
scores in 2017 and 2018 when asked, ‘What could you do to
improve education and training even more?’
2017 responses
“Reduce rota gaps by recruitment of more service focused doctors to
free up time and expertise for training. Ensure that service needs are
adequately met, with enough tiers of staff to provide a safe service,
with opportunities to educate and train.”
“An honest, clear advising/channelling of trainees down a more
obstetrics- or gynaecology-focused pathway at ST6/7.”
“A number of units mentioned scan simulators as a resource, which
would help support improved ultrasound training.”
“Use all 24 hours of the day more effectively for training, and ensure
staff are aware of trainees’ individual needs.”
“Ensure you maintain and develop an environment that is positive and
enthusiastic about improving everyone’s skills.”
“Focus on developing resilience, not just support.”
2018 responses
“Use trainee feedback to concentrate trainees in the better units.”
“Minimise the hoops to be jumped through to become or to remain an
Educational supervisor.”
“Don’t rest on your laurels.”
group of trainees, for example. Assessing trends in training
quality enables trainers to identify units where training is
improving or deteriorating, and this helps to ascertain
whether changes instigated by units are having positive
effects. The decision for a trainee to rate their unit positively
during a survey is likely to be multifactorial, and part of the
work of the TEC is to perform in-depth analysis of specific
themes to assess how they affect trainee perception. The
themes reviewed are as follows:
 Education – Support and supervision
 Education – Local training
 Education – Regional training
 Gynaecological training – General
 Gynaecological training – Procedural
 Gynaecological training – Basic ultrasound
 Obstetric training – General
 Obstetric training – Procedural
 Obstetric training – Basic ultrasound
 Professional development
 Clinical governance, hospital processes and resources
 Working environment
 Behaviours experienced
 Overall recommendation.
The full analyses18 and the 2018 reports19 are available on
the RCOG website.
Figures 2, 3 and 4 demonstrate that, according to the TEF,
good educational supervision, a good working environment
ª 2020 Royal College of Obstetricians and Gynaecologists

Figure 2. Results of the 2018 Training Evaluation Form showing the correlation between ‘Education – Support and supervision’ and ‘Overall
recommendation’.
Figure 3. Results of the 2018 Training Evaluation Form showing the correlation between ‘Working environment’ and ‘Overall recommendation’.
and experience of good behaviours are all positively
correlated with the overall recommendation of a unit. Of
the overall top ten units in 2018, four were in the top ten for
‘Education – Support and supervision’, four were in the top
ten for ‘Working environment’ and five were in the top ten
for ‘Behaviours experienced’, indicating that these are strong
indicators of a good training environment within a unit.
Rota gaps and lack of opportunities to attend Advanced
Training Skills Module sessions or specialist clinics harm the
training experience and are reasons for attrition cited
by trainees.
In the early 2000s, three themes were proposed that were
associated with a high-quality educational environment, and
these are shown in Figure 5.20 What is interesting about this
model is that it remains relevant to modern educational
practice, and the information gathered from highly effective
O&G units and the initiatives suggested by the RCOG and
ª 2020 Royal College of Obstetricians and Gynaecologists
O’Sullivan et al.
other national bodies largely fit into the three themes used in
this model.
Community
Trainees need to feel they are part of a community where
education is priority and which offers a sense of belonging. In
the best units, people spoke of striving for cohesion and
committing time and effort to achieving this. This goes
beyond teamworking – it is a truly working community.
Units need a sense of identity and joint ownership over
things that occur. Fellowship, wellbeing, safety and trust are
paramount. Trainees can often bring fresh ideas and
enthusiasm to units and their contributions to the
community should be valued. Although rotating through
units can be difficult, trainees have a responsibility to become
involved in the community of a unit, taking responsibility
151
 Effective training units

Figure 4. Results of the 2018 Training Evaluation Form showing the correlation between ‘Behaviours experienced’ and ‘Overall recommendation’.

Criticality
Criticality appears to be part of what makes professional people
A sense of
professionals. There may not be a right or wrong answer, but
community
professionals exercise their own judgement based on ‘practical
wisdom’ or ‘practical reasoning,’ thereby becoming reflective
practitioners. Trainees should be given time to discuss clinical
situations without feeling interrogated, but with guided
questioning to advance their thinking. Trainees should take
advantage of consultants’ wisdom and cultivate mentorship,
The highly
educational while consultants should value trainees’ perspectives as they
environment often view a unit through fresh eyes. Time should be made for
colleagues to reflect and think critically about their work. The
‘learning through excellence’ movement encourages
A commitment A culture of appreciative inquiry: asking questions to search for the best
to criticality collegiality in people and organisations and realising the resources and
potential within, for example, a training unit.21
A collaborative document from the Faculty of Medical
Leadership and Management, NHS Providers and NHS
Figure 5. Model showing the proposed three themes associated with
a high-quality educational environment.18
Improvement outlines eight high-impact actions (Box 4) to
improve the working environment for junior doctors.
Working with trusts and junior doctors, they have focused
not only for patient care, but also for their own learning. on ways to encourage engagement by junior doctors and
Trainees need to see themselves as part of the team, working developed actions that are meaningful and can be
together with all members of staff. initiated immediately.13
On the basis of these sources, as well as the feedback from
the best units across the UK, the Quality Criteria for
Collegiality
Obstetrics and Gynaecology Doctors in Training have been
Collegiality is more than corporate belonging; people should developed by the RCOG to support the roll-out of the new
feel they are colleagues more than staff, where they become a core curriculum. These can be seen in Appendix S1. These are
body of colleagues with a shared moral endeavour. There not designed to be standards that units must achieve or else
should be mutual acceptance and respect between face punishment, but a checklist against which units can
consultants and trainees, and this is a two-way process. benchmark themselves. If a unit can meet most of the quality
Units should feel they are not only working together, but also criteria, the authors propose that it is likely that the learning
learning together. environment within the unit will be good.

152 ª 2020 Royal College of Obstetricians and Gynaecologists


Box 4. Summary of the eight high-impact actions to improve
working conditions for junior doctors13
1. Promoting rest breaks and safe travel home
2. Improved access to food and drink 24/7
3. Rewarding excellence
4. Better engagement between trainees and the Board
5. Wellbeing, support and mentoring
6. Rotas that promote work–life balance
7. Clearer communication between trainees and management
8. Tackling work pressure
Conclusion
While it is important to tackle negative behaviours,
particularly the unacceptably high levels of bullying and
undermining in O&G,22,23 a lot can be learned from the
positive actions of the best performing training units.
Attrition rates among O&G trainees in the UK are high,
and this is concerning for the future of the workforce and of
women’s health. Many factors have been identified as
contributing to attrition, and a good learning environment
not only reduces attrition but improves patient safety.8 Many
of the factors that increase attrition will also have an impact
on training and education, so although separate issues,
initiatives to tackle one are likely to help with the other. Units
suffering from high attrition rates are also likely to struggle to
provide effective training to the remaining workforce due to
the need to cover the on-call rota and activities considered
‘service provision’.
Because of the nature of the specialty, there will be busy
shifts, and high-risk/high-stress and emotive situations.
While these aspects of the job cannot easily be changed,
some adjustments can be made, many of which are small,
that can make a big difference to the learning environment.
The challenges of the learning and clinical environment in
O&G have been analysed by previous RCOG Workforce
reports,23 and the information gained from more recent data
collection with the TEF can be added to these.
Using the Quality Criteria, units will be able to benchmark
themselves against the highly performing units. The criteria
should also provide ideas on how units can instigate change
to improve their learning environment. One of the key
functions of the RCOG is to drive improvements in
educational standards for specialty training. In collating
and disseminating feedback from highly performing units, it
is hoped that, alongside the Quality Criteria, units will feel
supported to change their training culture to
achieve excellence.
A number of the departments contacted after being highly
commended commented on their improvement trajectory
when they had previously been identified as having poor
ª 2020 Royal College of Obstetricians and Gynaecologists
O’Sullivan et al.
training performance. It is heartening to know that such
significant change is possible even in these challenging times,
and that making every unit an educationally excellent place
to work is both desirable and feasible.
Disclosure of interests
There are no conflicts of interests.
Contribution to authorship
JM and JF instigated and edited the article. MO’S and SN
researched and wrote the article. All authors approved the
final version.
Acknowledgements
The authors would like to thank Karen Brackley and Sonji
Clarke for their contributions to writing the Quality Criteria
and the whole Training Evaluation Committee for their
tireless efforts to collect, analyse and disseminate data to
improve training.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Appendix S1. Training unit quality criteria for obstetrics
and gynaecology.
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ª 2020 Royal College of Obstetricians and Gynaecologists