Struggling to find a clinical role?

Clinician academics are meant to work in both clinical and academic settings. Most AHP and nurse clinician academics I speak to struggle to achieve this.

Specifically, most struggle to find a workable clinician role. The extent that this affects people is hard to articulate – the exasperation, stress, upset and frustration.

Merely appreciating the current situation does little to resolve it, and I have no firm answers. But I’ll try to provide a description of how the situation looks like to me, and how I’m trying to navigate it at the moment.

The first layer of engagement: In engaging with NHS services and colleagues, their initial suggestion is often to consider and use me as an extra pair of hands for simple clinical tasks. They believe they are doing me a favour by allowing me to practice, and consider this as an easy way to tick that box. I always explicitly and politely discuss this (even if they don’t raise this as it’s still there on the background). I explain that I don’t work in this way because it’s poor use of taxpayers’ money. The taxpayer has paid a lot to train me (10 years post-grad on full salary plus all training and research fees), and is now paying me a senior salary. It makes no sense to use me for tasks that don’t match my pay band – one wouldn’t do that with any other clinician. Also, using me just as an extra paid of hands limits my contribution to advancing patient care, and this brings ethical dilemmas. E.g. I have seen colleagues carrying out practices that, in light of research evidence, really trouble me. Yet, I’ve been powerless to support change in these if the service hasn’t wanted to involve me beyond the basic tasks.

The second layer: Ruling out the simple-tasks engagement is usually followed by them asking me: “Ok, so what could you do then?”. On surface, this fits with the narrative that NHS welcomes clinician academics and that all we need to do is propose how to use us. However, in my experience, while the services may say this, they are usually much less keen on listening to my ideas. This observation aligns with evidence that providing people information (e.g. information about what you can do and why it might be a good idea) is largely ineffective in influencing what the people do. I have an explicit rule: never seek to persuade. So, I skip their question, and this layer, and move on to layer three.

The third layer: This layer is past the initial chit chat and into building genuine working relationships. I believe it requires the use of all the good relationship skills, e.g. listening, honesty, and respect. With persuation still off the table, a few other techniques have emerged as consistent winners:

▪ Goals. If I can figure out what the service, the manager, or the clinician tries to achieve then I can usually find a way to work with them. I like to contribute to delivering common goals, and I’m not too precious about getting credits (within reason). If they have a goal that fits with my broad values and if I think I can meaningfully contribute, then I’m usually happy to give it a go. Even if we don’t achieve the goal we might learn to work together.

▪ Sit it out. A lot of things take a very long time to come to fruition. I’m not patient by nature, and this frustrates the life out of me. But I try to recognise what is and isn’t in my powers, work on things where I can actually achieve progress, and accept that people often need quite a bit of time (from several months to years) to be ready to progress something together.

▪ Give more than you take, but do not help at all cost. This is what I do, but I’m not sure it’s always for the best. I’m actually trying to help less (because it’s taking too much of a toll on me) and exchange more. But often I find it hard to tell if something is exchanging or helping, and to be on the safe side I still help quite a lot more than I take. But I do keep a black list and I don’t hesitate to disengage if people are taking me for a fool.

▪ Formal role with deliverables. Try to agree a very specific role and negotiate key things you will deliver. This follows from the goals, but requires quite a bit of additional negotiation. In my experience NHS services, managers and clinicians aren’t used to thinking about specific deliverables and outputs, and even the process of identifying and agreeing these can be quite challenging. Where I can agree these, I have found that delivering the outputs is one of the best ways to demonstrate what I can do.

The fourth layer: For quite a while I thought that identifying the goals and agreeing the formal role was the winning combination. I thought that if I could do these then I would be in a good position to contribute to the NHS. But I have been proven wrong.

The fourth layer is about people seeing me – not just looking through me – and engaging me to planning, decision making and delivery. I find it that even with agreed goals and roles NHS managers and colleagues often do not see me. E.g., they sit next to me at a meeting and say “We don’t have any Consultant AHPs in our Trust” (ehm… that’s me, that’s what it says on my contract with you….?) or “I am the only OT at this meeting” (eh? I am a qualified, registered OT practicing clinically alongside you, in the same team, and you are looking straight at me….?). When I challenge people about these they say “Yes, I know you are, but…” and explain they do not consider me as a proper Consultant AHP/OT/etc. I genuinely do not think it’s personal. I think they just do not see me as part of the system.

I now believe that the only way around this is to have formal NHS positions for AHP and nurse clinician academics. Positions that are visible within the organisational chart, that come with agreed deliverables and responsibilities, and that have actual teeth and authority. I believe these roles should be jointly funded with a research intensive university, with clear deliverables and responsibilities for research too. This is to ensure the people who are appointed remain actively academically engaged.

Some of the current fellowships are perceived to be a way to avhieve this, but I am still to see this working in practice. The fellowship schemes place the responsibility on the fellow who in reality does not have the power to create a recognised role for themselves. In my experience the NHS part of the fellowship applications and reports becomes too easily an exercise in creative writing instead of ensuring implementation of clinical academic roles.

So what do I think is the solution? I genuinely am not sure. At the moment I believe that a lot of it boils down to the senior managers and then to the clinician academics themselves.

I think bravery by senior NHS managers is key. Recruit that person with a PhD to the clinical leadership role. Give it to them part-time so they can continue to lead relevant research. Specify clear deliverables for them, and hold them accountable. Demand the same good leadership of them as you would of anyone. Provide support, but also allow them to be ambitious and be open to their new ways of doing things. And show them that you see them, by actively engaging them and using them. If you see them, everyone else will too.

Equally important are the clinician academics. We all need good quality mentoring, and need to make sure our leadership behaviours are top notch. It’s not enough just to know research, have publications, and hang out in national working groups. A much wider set of skills, especially relationship and leadership skills, is needed to deliver on NHS clinical academic leadership roles.