A total of eighteen participants participated in nine IDIs and two FGDs. IDI participants included four MSWs, one MSW supervisor and four senior hospital Trust directors. One FGD was conducted with a total of four MSW supervisors and six senior hospital Trust directors and one FGD was conducted with five MSWs. Some of those present in the FGDs were also interviewed during the IDIs.
Themes and sub-themes emerging from the data could be categorised into those relating to three different levels of the health system (micro, meso and macro-levels), and are presented in Figure 1.
Micro-Level: Who are the MSWs?
At the micro-level of individuals within the health system, a major theme identified, related to ‘who are the MSWs?’, with sub-themes around diversity, their supernumerary role at OUHFT, as well as attitudes and perceptions of the participants to the MSW role.
Diversity
The MSWs at OUHFT came from diverse cultural backgrounds. The majority of the MSWs who joined the OUHFT as MSWs were international medical graduates, with a very small number of unlicensed UK medical graduates. The MSWs were also diverse in their medical experiences and specialisations, with some having several years of working experience in general practice, geriatrics, emergency medicine, paediatrics, surgery and obstetrics and gynaecology. This cultural and professional diversity was viewed by senior hospital staff as an asset to the Trust.
“The most exhilarating and joyful thing for me was the diversity.”
- Senior Manager
Supernumerary role
MSWs were perceived as supernumerary members of the medical team working under direct supervision of registered medical practitioners at OUHFT. Although their responsibilities were flexible within the various departments at OUHFT, their responsibilities were limited due to regulations which did not permit MSWs to make clinical decisions without supervision, nor to prescribe medication or ionising radiation. Despite some of the MSWs’ broad experience as doctors in their home countries, MSWs were seen by some senior stakeholders as being similar in background to pre-licensed medical students who work under supervision.
“So, MSWs can’t prescribe drugs. And they can’t prescribe ionising radiation. But under supervision, they can do things like a medical student, I think that’s a really good analogy because a medical student is someone with medical training pre-licensed, and that’s what MSWs are”.
– Director A
MSWs were aware of the limitations of their role, which at times could be frustrating, particularly for those with more experience as doctors. Their roles were mainly to assist the foundation year 1 doctors (FY1) at OUHFT in order to decrease FY1 doctors’ workload.
“I have to work in a very extremely restricted area. Basically, what I do is I am helping out the F1s. So, I am basically helping them out to ease out their workloads.”
– MSW D
Attitudes and perceptions towards the MSW role
Both MSWs and their supervisors showed an overwhelmingly positive attitude toward their role in the NHS. The MSW role provided IMG doctors with a sense of purpose and accomplishment, raising their self-esteem and well-being. Working as a medical practitioner in clinical settings had been a rewarding job for IMG doctors. However, they had been forced to take a break from their respective clinical fields after moving to the UK due to the challenges of getting a GMC license, and it was affecting their mental health. They shared that the MSW position provided them with an opportunity to regain their sense of accomplishment of working in the clinical setting as a medical practitioner.
“I could remember what I said to myself when I got my medical practice licence, I said to myself that I am fulfilled. So, for me to get to this country, I am not able to participate or do things that I really like doing. It was really affecting me, mentally. But, when I got this opportunity, I felt fulfilled again!”
-MSW A
The supervisors spoke about the strong clinical knowledge and experience of the MSWs, which was contributing to support the work of FY1 doctors. Supervisors shared their interest to work with more MSWs and acknowledged their importance within their clinical teams.
“I would like at least want five of them on my unit and if I could get five medical support workers as good as these people, it would support the FY1 doctors no end.”
- MSW Supervisor
However, participants also mentioned that the MSW role was not clearly understood by patients or other healthcare professionals outside of their immediate teams. MSWs spoke about the challenges they face in explaining who they are and their role to patients as they are not permitted to introduce themselves as doctors. However, MSWs reported that they had been able to communicate with patients effectively without overstepping the limit of their roles.
Contribution during COVID 19 Pandemic
Prior to joining the NHS as MSWs, some IMGs played an important role in contributing to the NHS during the COVID-19 pandemic. This experience helped them understand the working culture in the NHS, particularly with regard to communicating with patients.
“Since I have been in the UK, during the pandemic, I have worked as a vaccinator, which is was a good thing, I was able to meet the patients and then talk to them, relay through them as it helped me the way of communicating the patients in the UK.”
-MSW A
Meso Level – Importance of NHS Trust Induction:
At the meso-level of the Hospital Trust, the importance of providing hospital-level inductions tailored to the needs of the MSWs was recognised, considering their diverse backgrounds. Induction was seen as important to clarify the MSW role to both MSWs and the wider team, to enable integration into the medical team, and also from a practical perspective to understand the health system and the logistics of patient records.
Job Clarity
The MSWs reported the importance of having clear guidance regarding their role and responsibilities, and the limitations of the position. One MSW shared how a one-on-one induction with her mentor or supervisor helped her have clarity about her assigned responsibilities as a MSW.
“Well, initially, I was very confused and was in doubt with myself during first two weeks. During that period, I was just going through like what is happening? What the role that I have to do? But the interview with my mentor, he told me, what we have to like focus on…., in that process I also used to see what other tasks we were supposed to do.”
– MSW C
Task-sharing was a major part of the MSWs’ responsibilities in the Trust. Hence, it was also important that the co-workers of the MSWs have clear knowledge about the assigned responsibilities and limitations of the MSW position to avoid confusion about MSWs’ role in the team. Besides, at the initial stage of the job, allowing the MSWs sufficient time and space to learn new knowledge and adjust to the new clinical environment was also seen as useful to get a good grasp of their responsibilities.
Integration into the wider team
MSWs were assigned to work in distinct departments at the OUHFT based on their clinical expertise. The supervisors of the MSWs played an important role in integrating MSWs into the wider team.
“I really want them to work…want them to get the best out of this job. For that, I have absolutely, made sure that they are introduced to my department, which is very busy, in a very slow, conservative, and supportive manner. Encouraging them within team so that the team knows who they are and they are not just an outlier, making sure when there is teaching for the FY1s, they are brought along to it and included in that team, because otherwise, I worried that they would lose identity, be seen as potentially someone sat and not doing very much, and they are absolutely not that.”
– MSW Supervisor A
The MSWs shared that the friendly and supportive attitudes of their colleagues and supervisors made them feel welcomed in the team as well as helped them greatly in adapting to this new role as MSW.
Familiarisation with Electronic Patients Record
For the majority of MSWs, it was their first time using an Electronic Patient Record (EPR) system, as digitalised systems for recording patients’ information were rarely available in the hospitals in their respective countries. The MSWs shared facing stress and difficulties in learning and being accustomed to working with EPR.
“The EPR that we use has been very challenging. This is the first time I am using that kind of system. I have used something like that before even back in Nigeria. But this is much more complex.”
- MSW A
In addressing the challenges faced by the MSWs in using EPR at OUHFT, the trust organised training on the EPR system as part of the induction process for the MSWs. The supervisors also emphasised familiarising the MSWs with online EPR training.
“For that, I have absolutely, made sure…That’s, all their ID is got, all their online learning, making sure that they know how to use the computers”
– MSW Supervisor A
Macro Level – Long-term vision for the MSWs
At the macro-level, looking at the national picture in relation to the MSW role, the long-term prospect of MSWs’ integration into NHS England was highlighted. The MSW role enabled IMGs to get paid whilst contributing to the NHS, gaining experience of the NHS and integrating into a new health system, whilst also studying for their exams to become a licensed medical practitioner in the UK.
General Medical Council License
Acquiring the license from GMC for clinical practice in the UK through successful completion of the PLAB test was the long-term vision and goal shared by all IMGs working as MSWs at OUHFT. However, due to high demand, getting a slot for the PLAB test required a long waiting time. The MSWs communicated that the role of MSW was an ideal opportunity for them to effectively utilise this period of waiting to receive a GMC license, whilst gaining the opportunity to work in the NHS and clinical experience in the UK. They also reported that working as an MSW was an effective learning experience, and helpful for their future PLAB test.
Integration to NHS
Senior managers at the OUHFT felt that the MSW scheme was helpful in integrating the IMGs into the NHS without delay and fostering their career progression within the NHS, which would eventually help in addressing the existing healthcare workforce shortage in the NHS. One director said:
“Well, I mean we need to extend the workforce. Don’t we? And, you know, a lot of people who trained overseas have had to wait for the PLAB, and have had difficulty becoming useful to the NHS in their doctor role, so, it strikes me as a good idea to get people upskilled to point they can safely take on a medical junior role and become accustomed to the NHS.”
- Director B
Funding
The employers of the MSWs at OUHFT stated that the short-term recruitment of MSWs was funded through a national scheme by NHS England delivered to Hospital Trusts. They considered this scheme as an investment to mitigate existing workforce shortages of doctors in the NHS and hoped for further support for this scheme in the future to recruit more MSWs, with the extension of national funding.
“Certainly, at the moment, I think, it’s seen as an investment”
– Director B
“I would really like it if we keep on providing this role so, we got people when they come [to the UK]. I don’t know if there will be funding for that. It would be great if we can start seeing the benefits of doing that.”
– Director D
Similarly, MSWs reported the benefit of extending the duration of the role and that they now wanted to contribute to the NHS and work within the health system in the long-term.
“So, continuation of this and then transition to another job as a licensed medical practitioner would do me so much good, would help me in so many ways, would make me a better doctor because I don’t want to leave the country now, I have my family here, I would want to move on with my career.”
- MSW C