Hospital Doctor Retention and Motivation Project

We are conducting research on doctor emigration and retention

The Hospital Doctor Retention and Motivation project is a four-year research project (2018-2021) hosted by RCPI and funded by the Health Research Board (Emerging Investigator Award).

The Irish health system faces a medical workforce crisis as a result of weak retention and unchecked doctor emigration.

Health system responses to date have been focused on supply-side measures (training more doctors, recruiting doctors internationally), meaning that Ireland has been changing the doctors in the system, rather than changing the system itself.

The Hospital Doctor Retention and Motivation project will focus on hospital doctor retention and on doctor motivation.

Using qualitative and quantitative research methods and fieldwork in Ireland and Australia, we will seek to generate information to inform and improve doctor retention policy and practice in the Irish health system.

HDRM Remote Ethnography

In Summer 2021 we will begin the fourth phase of the HDRM project.. Our next step is to learn more about doctors’ working lives on a day-to-day basis, particularly how COVID-19 and COVID-related changes have impacted the work experiences of hospital doctors. The team will use remote  ethnography to do this. Our original plan was to use ethnographic methods  to shadow participating hospital doctors in-person while they worked, to find out more about their everyday experience of work. 
However, in light of Covid-19, we will instead use remote ethnography. This means that we will use digital technology (WhatsApp and Zoom) to connect with participant hospital doctors. We will invite these hospital doctors to share their reflections on their day-to-day experiences of work. We start with an interview (by zoom) to find out about the participant and their work. Then we invite them to take part in a conversation (via WhatsApp) over a 12-week period. Each week, the HDRM researchers will send 2-3 questions or prompts about work, inviting the participant to respond at a time that suits them. Find out more about remote ethnography here.

 

Cartoon ©Eoin Kelleher, 2020. This cartoon was commission for the HDRM project, and reflects our process of doctor-centred and collaborative qualitative research.

The reflections gathered via Zoom and WhatsApp will provide valuable insights into the working conditions of Ireland’s hospital doctors in 2021. We will share this information with policy makers to assist in the strengthening of the medical workforce post- COVID-19.

You can find out more about what participation involves in the Participant Information Leaflet below. If you would like to take part, or to find out more, email us at hdrm2020@rcpi.ie.

HDRM Remote Ethnography: Participant Information Leaflet

Find out more about what the HDRM Remote Ethnography: what ethnography is, what participation will involve, how data will be collected, stored and used, what supports are available during participation, and how you and your hospital will benefit.

View our publications:

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Creese, J., Byrne, J.-P., Matthews, A., McDermott, A. M., Conway, E., & Humphries, N. (2021). “I feel I have no voice”: hospital doctors' workplace silence in Ireland. Journal of Health Organization and Management, 35(9), 178-194. doi:10.1108/JHOM-08-2020-0353

Workplace silence impedes productivity, job satisfaction and retention, key issues for the hospital workforce worldwide. It can have a negative effect on patient outcomes and safety and human resources in healthcare organisations. This study aims to examine factors that influence workplace silence among hospital doctors in Ireland. A national, cross-sectional, online survey of hospital doctors in Ireland was conducted in October–November 2019; 1,070 hospital doctors responded. This paper focuses on responses to the question “If you had concerns about your working conditions, would you raise them?”. In total, 227 hospital doctor respondents (25%) stated that they would not raise concerns about their working conditions. Qualitative thematic analysis was carried out on free-text responses to explore why these doctors choose to opt for silence regarding their working conditions.

Reputational risk, lack of energy and time, a perceived inability to effect change and cultural norms all discourage doctors from raising concerns about working conditions. Apathy arose as change to working conditions was perceived as highly unlikely. In turn, this had scope to lead to neglect and exit. Voice was seen as risky for some respondents, who feared that complaining could damage their career prospects and workplace relationships. This study highlights the systemic, cultural and practical issues that pressure hospital doctors in Ireland to opt for silence around working conditions. It adds to the literature on workplace silence and voice within the medical profession and provides a framework for comparative analysis of doctors' silence and voice in other settings.

https://doi.org/10.1108/JHOM-08-2020-0353
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Byrne, J.-P., Conway, E., McDermott, A. M., Matthews, A., Prihodova, L., Costello, R. W., & Humphries, N. (2021). How the organisation of medical work shapes the everyday work experiences underpinning doctor migration trends: The case of Irish-trained emigrant doctors in Australia. Health Policy, 125(4), 467-473. doi:10.1016/j.healthpol.2021.01.002

Medical migration is a global phenomenon. In Ireland, hospital doctor emigration has increased significantly in recent years, with Australia a destination of choice. With work and employment conditions cited as a driver of these trends, this article explores how health system differences in the organisation of medical work shape the everyday experiences of hospital doctors which underpin migration decisions. Drawing on 51 semi-structured interviews conducted in July-August 2018 with Irish-trained hospital doctors who had emigrated to work in Australia, the findings highlight doctors’ contrasting experiences of medical work in the Irish and Australian health systems. Key system differences in the organisation of medical work manifested at hospital level and related to medical hierarchy; staffing, support and supervision; and governance and task coordination. Findings indicate that retention of hospital doctors is as much about the quality of the work experience, as it is about the quantity and composition of the workforce. At a time of international competition for medical staff, effective policy for the retention of hospital doctors requires an understanding of the organisation of work within health systems. Crucially, this can create working contexts in which doctors flourish or from which they seek an escape.

https://doi.org/10.1016/j.healthpol.2021.01.002
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Creese, J., Byrne, J.-P., Conway, E., Barrett, E., Prihodova, L., & Humphries, N. (2021). “We all really need to just take a breath”: composite narratives of hospital doctors’ well-being during the COVID-19 Pandemic. International journal of environmental research and public health, 18(4), `2051. doi:10.3390/ijerph18042051

The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to the physical and mental well-being of doctors worldwide. Countries around the world introduced severe social restrictions, and significant changes to health service provision in the first wave of the pandemic to suppress the spread of the virus and prioritize healthcare for those who contracted it. This study interviewed 48 hospital doctors who worked in Ireland during the first wave of the pandemic and investigated their conceptualizations of their own well-being during that time (March–May 2020). Doctors were interviewed via Zoom™ or telephone. Interview transcripts were analyzed using structured thematic analysis. Five composite narratives are presented which have been crafted to illustrate themes and experiences emerging from the data. This study found that despite the risks of contracting COVID-19, many doctors saw some improvements to their physical well-being in the first wave of the pandemic. However, most also experienced a decline in their mental well-being due to anxiety, emotional exhaustion, guilt, isolation and poor support. These findings shed light on doctor well-being during COVID-19, and the ways in which they have been affected by the pandemic, both professionally and personally. The paper concludes by highlighting how doctors’ work life and well-being can be better supported during and after the COVID-19 pandemic

https://doi.org/10.3390/ijerph18042051
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Humphries, N., Creese, J., Byrne, J.-P., & Connell, J. (2021). COVID-19 and doctor emigration: the case of Ireland. Human Resources for Health, 19(1), 29. doi:10.1186/s12960-021-00573-4

Since the 2008 recession, Ireland has experienced large-scale doctor emigration. This paper seeks to ascertain whether (and how) the COVID-19 pandemic might disrupt or reinforce existing patterns of doctor emigration. This paper draws on qualitative interviews with 31 hospital doctors in Ireland, undertaken in June–July 2020. As the researchers were subject to a government mandated work-from-home order at that time, they utilised Twitter™ to contact potential respondents (snowball sampling); and conducted interviews via Zoom™ or telephone.

Two cohorts of doctors were identified; COVID Returners (N = 12) and COVID Would-be Emigrants (N = 19). COVID Returners are Irish-trained emigrant doctors who returned to Ireland in March 2020, just as global travel ground to a halt. They returned to be closer to home and in response to a pandemic-related recruitment call issued by the Irish government. COVID Would-be Emigrants are hospital doctors considering emigration. Some had experienced pandemic-related disruptions to their emigration plans as a result of travel restrictions and border closures. However, most of the drivers of emigration mentioned by respondents related to underlying problems in the Irish health system rather than to the pandemic, i.e. a culture of medical emigration, poor working conditions and the limited availability of posts in the Irish health system. This paper illustrates how the pandemic intensified and reinforced, rather than radically altered, the dynamics of doctor emigration from Ireland. Ireland must begin to prioritise doctor retention and return by developing a coherent policy response to the underlying drivers of doctor emigration.

https://doi.org/10.1186/s12960-021-00573-4
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Byrne, J., Conway, E., McDermott, A., Costello, R., Prihodova, L., Matthews, A., & Humphries, N. (2021). Between Balance and Burnout: Comparing the Working-time Conditions of Irish Hospital Doctors in Ireland and Australia. In Montgomery A, Van der Doef M, Panagopoulos E, & Leiter M (Eds.), Connecting Healthcare Worker Well-Being, Patient Safety and Organisational Change: The Triple Challenge: Springer.

Health systems internationally are contending with medical workforce crises characterised by high rates of burnout and turnover intention. Research from Ireland has shown how excessive work demands challenge the working lives of hospital doctors, who often find themselves having to choose between remaining in a health system under strain (risking burnout) or emigrating to seek more balanced work-life conditions. Drawing on semi-structured interviews with 51 Irish-trained doctors who have emigrated to work in Australia, the chapter contrasts their experience of work-time in Ireland and Australia. Using a psychosocial work environment (PWE) lens, we highlight the four features of work-time which participants drew on to contrast their experiences: the quantity of work hours, the quality of work and non-work time, the predictability of work-time, and employment flexibility. Work-time in Ireland was characterised by conditions associated with burnout (intensity, extended hours, unpredictability, work-life conflict), whereas work-time in Australia was typified by conditions relating to balance (bounded and predictable hours, moderated work intensity, flexibility). The chapter presents a theoretical framework which delineates these temporal conditions of balance and burnout, illustrating how they are generated by institutional and organisational contexts, and are critical in shaping the working lives and well-being of hospital doctors.

https://link.springer.com/chapter/10.1007/978-3-030-60998-6_6
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Humphries, N., McDermott, A. M., Creese, J., Matthews, A., Conway, E., & Byrne, J.-P. (2020). Hospital doctors in Ireland and the struggle for work-life balance. European Journal of Public Health, 30(4), iv32–iv35. doi:10.1093/eurpub/ckaa130

Ireland has a high rate of doctor emigration. Challenging working conditions and poor work–life balance, particularly in the hospital sector, are often cited as a driver. The aim of this study was to obtain insight into hospital doctors’ experiences of work and of work–life balance. In late 2019, a stratified random sample of hospital doctors participated in an anonymous online survey, distributed via the national Medical Register (overall response rate 20%; n = 1070). This article presents a qualitative analysis of free-text questions relating to working conditions (n = 469) and work–life balance (n = 314). Results show that respondent hospital doctors, at all levels of seniority, were struggling to achieve balance between work and life, with work–life imbalance and work overload being the key issues arising. Work–life imbalance has become normalized within Irish hospital medicine. Drawing on insights from respondent hospital doctors, this study reflects on the sustainability of this way of working for the individual doctors, the medical workforce and the Irish health system. If health workforce planning is about getting the right staff with the right skills in the right place at the right time to deliver care, work–life balance is about maintaining doctor wellbeing and encouraging their retention.

https://doi.org/10.1093/eurpub/ckaa130
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Humphries, N., McDermott, A., Conway, E., Byrne, J., Prihodova, L., Costello, R., & Matthews, A. (2019). ‘Everything was just getting worse and worse’: deteriorating job quality as a driver of doctor emigration from Ireland. Human Resources for Health, 17(1), 97. doi:10.1186/s12960-019-0424-y

Medicine is a high-status, high-skill occupation which has traditionally provided access to good quality jobs and relatively high salaries. In Ireland, historic underfunding combined with austerity-related cutbacks has negatively impacted job quality to the extent that hospital medical jobs have begun to resemble extreme jobs. Extreme jobs combine components of a good quality job—high pay, high job control, challenging demands, with those of a low-quality job—long working hours, heavy workloads. Deteriorating job quality and the normalisation of extreme working is driving doctor emigration from Ireland and deterring return. Semi-structured qualitative interviews were conducted with 40 Irish emigrant doctors in Australia who had emigrated from Ireland since 2008. Interviews were held in July–August 2018.

Respondents reflected on their experiences of working in the Irish health system, describing hospital workplaces that were understaffed, overstretched and within which extreme working had become normalised, particularly in relation to long working hours, fast working pace, doing more with less and fighting a climate of negativity. Drawing on Hirschman’s work on exit, voice and loyalty (1970), the authors consider doctor emigration as exit and present respondent experiences of voice prior to emigration. Only 14/40 respondent emigrant doctors intend to return to work in Ireland. The deterioration in medical job quality and the normalisation of extreme working is a key driver of doctor emigration from Ireland, and deterring return. Irish trained hospital doctors emigrate to access good quality jobs in Australia and are increasingly likely to remain abroad once they have secured them. To improve doctor retention, health systems and employers must mitigate a gainst the emergence of extreme work in healthcare. Employee voice (about working conditions, about patient safety, etc.) should be encouraged and used to inform health system improvement and to mitigate exit.

https://doi.org/10.1186/s12960-019-0424-y
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Humphries, N., Connell, J., Negin, J., & Buchan, J. (2019). Tracking the leavers: towards a better understanding of doctor migration from Ireland to Australia 2008–2018. Human Resources for Health, 17(1), 36. doi:10.1186/s12960-019-0365-5

The recession of 2008 triggered large-scale emigration from Ireland. Australia emerged as a popular destination for Irish emigrants and for Irish-trained doctors. This paper illustrates the impact that such an external shock can have on the medical workforce and demonstrates how cross-national data sharing can assist the source country to better understand doctor emigration trends. This study draws on Australian immigration, registration and census data to highlight doctor migration flows from Ireland to Australia, 2008–2018. 

General population migration from Ireland to Australia increased following the 2008 recession, peaked between 2011 and 2013 before returning to pre-2008 levels by 2014, in line with the general economic recovery in Ireland. Doctor emigration from Ireland to Australia did not follow the same pattern, but rather increased in 2008 and increased year on year since 2014. In 2018, 326 Irish doctors obtained working visas for Australia. That doctor migration is out of sync with general economic conditions in Ireland and with wider migration patterns indicates that it is influenced by factors other than evolving economic conditions in Ireland, perhaps factors relating to the health system.

Doctor emigration from Ireland to Australia has not decreased in line with improved economic conditions in Ireland, indicating that other factors are driving and sustaining doctor emigration. This paper considers some of these factors. Largescale doctor emigration has significant implications for the Irish health system; representing a brain drain of talent, generating a need for replacement migration and a high dependence on internationally trained doctors. This paper illustrates how source countries, such as Ireland, can use destination country data to inform an evidence-based policy response to doctor emigration.

https://doi.org/10.1186/s12960-019-0365-5

Hospital Doctor Retention and Motivation: five study phases

The Hospital Doctor Retention and Motivation research project will have five study phases:

  • Phase 1: Interviews with Irish-trained doctors in Australia (2018)
  • Phase 2: National survey of hospital doctors (2019)
  • Phase 3: COVID HDRM (2020)
  • Phase 4: Remote Ethnography (2021)
  • Phase 5: Knowledge Exchange (2018-21)
Cartoon ©Eoin Kelleher, 2020. This cartoon was commission for the HDRM project, and is informed by findings from phase 3 of the HDRM project

PHASE 3: COVID HDRM (2020)

Over a 4-week period in June and July 2020, the HDRM team conducted 48 qualitative interviews (via video-call and phone) with  hospital doctors  to find out how they fared during the first wave of the COVID-19 pandemic. We would like to thank all of the hospital doctors who participated in the interviews who told us incredible stories about working through COVID-19 and who also shared their hopes and fears for the Irish health system going forward.

Interviews were analysed August-October 2020. The main findings from our analysis of these interviews were presented to senior policymakers in March 2021. The HDRM team have published several papers from this phase of the project, focused on emigration, wellbeing and the experiences of NCHDs. If you would like to access these, see our publications section above, and see future updates posted here and @HDRM_Project.

PHASE 2: Survey of Hospital Doctors in Ireland (2019)

In late 2019, HDRM (with the assistance of the Medical Council) conducted a cross-sectional survey of hospital doctors in Ireland. 1070 doctors responded to the survey which focussed on their working conditions, work-life balance, and job satisfaction. The main survey findings were presented to senior policymakers at a HDRM policy dialogue held in RCPI on 27th February 2020. The HDRM team have published several papers from this phase of the project, focussed on work-life balance, work-life conflict, and voice in the workplace. If you would like to access these, see our publications section above, and see future updates posted here and @HDRM_Project.

PHASE 1: Interviews with Irish-trained doctors in Australia (2018)

In 2018 we focused on Irish-trained doctors in Australia, as Australia was then the top destination country for emigrant Irish-trained doctors. This phase of the project involved interviewing 51 Irish doctors in Australia about their decision to migrate, their experiences working in Ireland and in Australia, and their perspectives on return. This information was used to help Irish policymakers better understand the patterns of doctor migration flows from Ireland to Australia and the reasons for that migration. Initial findings were published in the Irish Times and presented to the Health Research Board and to senior policymakers. We have published four papers from this research. If you would like to access these, see our publications section above.

This research will seek to find out why our highly-trained hospital doctors are emigrating and how best to motivate them to either stay in Ireland or to return to practice medicine in Ireland. The project will contribute to our understanding of doctor emigration, retention and workplace morale, and seeks to inform national health workforce policy.

Niamh Humphries PhD

Reader in Health Systems Research

Meet the HDRM team

From left to right:

Dr Niamh Humphries (Reader in Health Systems Research),

Dr Jennifer Creese (Postdoctoral Researcher) and

Dr John-Paul Byrne (Postdoctoral Researcher) 

Contact us

Dr Niamh Humphries

Reader in Health Systems Research

Tel: +353 1 8639 693

Dr Niamh Humphries is a Reader in Health Systems Research who joined the Royal College of Physicians of Ireland in April 2016. She holds a PhD in Sociology and has worked in health workforce research since 2006.  In 2017 she was awarded a prestigious HRB Emerging Investigator Award for a 4 year research project focussed on hospital doctor retention and motivation, which will involve fieldwork in Ireland and Australia. Her current research interests are health worker migration, health worker retention and the working lives of health workers.

Dr John-Paul Byrne

Postdoctoral Researcher

Tel: +353 1 8639 693

Dr John-Paul Byrne joined the Royal College of Physicians of Ireland in February 2019 as Postdoctoral Researcher with the HDRM Project. He holds a PhD in Sociology from Maynooth University and has previously held research positions on projects studying working conditions in Ireland and Denmark, and the experience of patient-centred care in Ireland. John-Paul is a recipient of the Government of Ireland Postgraduate Scholarship from the Irish Research Council (2012). His current research interests are psychosocial work conditions, working lives, and the social structures of work in healthcare.

Dr Jennifer Creese

Postdoctoral Researcher

Dr Jennifer Creese joined the Royal College of Physicians of Ireland in February 2020 as Postdoctoral Researcher with the HDRM Project. She holds a PhD in Social Science from The University of Queensland, Australia, specialising in social anthropology and ethnography. She has previously held research positions studying migration experiences, health care resilience, and dementia family care in Australia. Jennifer is the recipient of an Australian Federal Government Australian Postgraduate Award and Research Training Program scholarship 2015-2019. Her current research interests are migrant health worker experiences, health care organizational cultures and the working lives of health workers.