BMJ Open is committed to open peer review. As part

BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected]

BMJ Open

Perceived Organizational Support and Career Intentions: The Stories Shared by Early Career Doctors

Journal: Manuscript ID

BMJ Open bmjopen-2018-022833

Fo

Article Type:

Date Submitted by the Author:

Research 08-Mar-2018

rp

Complete List of Authors:

rr

ee

Scanlan, Gillian; University of Aberdeen Institute of Applied Health Sciences, Centre for Healthcare Education Research and Innovation (CHERI), Institute of Education for Medical and Dental Sciences, School of Medicine, Dentistry and Nutrition Cleland, Jennifer; University of Aberdeen Walker, Kim; NHS Education for Scotland., NHS Education for Scotland and UK Foundation Programme Johnston, Peter; NHS Education for Scotland, North Deanery MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, EDUCATION & TRAINING (see Medical Education & Training), OCCUPATIONAL & INDUSTRIAL MEDICINE

iew

ev

Keywords:

ly

on For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 1 of 44

Perceived Organizational Support and Career Intentions: The Stories Shared by Early Career Doctors Gillian Scanlan1, Jennifer Cleland1, Kim Walker2 and Peter Johnston2

1

Centre for Healthcare Education Research and Innovation (CHERI), Institute of Education for

Medical and Dental Sciences, School of Medicine, Dentistry and Nutrition, University of Aberdeen, Aberdeen, Foresterhill, AB25 2ZD 2

Fo

NHS Education for Scotland, Scotland Deanery (North), Foresterhill.

rp

Correspondence to: Ms Gillian Scanlan

ee

Email: [email protected]

iew

ev

rr ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

Abstract Context: The wish to quit or at take time out of medical training appears to be related, at least in part, to a strong desire for supportive working and learning environments. However, we do not have a good understanding of what a supportive culture means to early career doctors, and how perceptions of support may influence career decision making. Our aim was to explore this in UK Foundation doctors. Methods: This was a qualitative study using semi-structured interviews incorporating a narrative

Fo

inquiry approach for data collection. Interview questions were informed by the literature as well as

rp

data from two focus groups. Interviews were carried out in two UK locations. Initial data coding and analysis were inductive, using thematic analysis. We then used the lens of Perceived Organizational

ee

Support (POS) to group themes and aid conceptual generalizability.

rr

Results: Twenty-one interviews were carried out. Eleven interviewees had applied for specialty training, while ten had not. Support from senior staff and colleagues influenced participants’ job

ev

satisfaction and engagement. Positive relationships with senior staff and colleagues seemed to act as

iew

a buffer, helping participants cope with challenging situations. Feeling valued (acknowledgement of efforts, and respect) was important. Conversely, perceiving a poor level of support from the organization and its representatives (supervisors, colleagues) had a detrimental impact on participants’ intentions to stay working within the NHS.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 2 of 44

Conclusion: Overall, this is the first study to explore directly how experiences in early postgraduate training have a critical impact on the career intentions of trainee/resident doctors. We found perceived support in the early stages of postgraduate training was critical to whether doctors applied for higher training and/or intended to stay working in the NHS. These findings have transferable messages to other contexts struggling to recruit and retain junior doctors.


Page 3 of 44

Strengths and Limitations of this Study •

This study used a narrative inquiry approach to capture meaningful and purposeful stories that would resonate with readers and thus not lose critical elements of the experiences of early career doctors.

•

Interviews were carried out with F2 doctors during their foundation programme, therefore the experiences and stories shared were in direct observation to their working and learning environment, and thus were not in danger of recall bias.

•

Fo

It builds on the existing literature that directly relates to factors that influence career decision making of early career doctors and addresses the limitations of previous work by

rp

using the social theory of Perceived Organizational Support as a theoretical conceptual

ee

framework to provide deeper insight and the use of semi-structured interviews to gain thorough understanding of this phenomenon. •

rr

It is limited as we only interviewed F2 doctors from Scotland, and perhaps the views of those

ev

in Scotland may not be representative of those from the rest of the UK.

iew

Introduction

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Early medical careers decision making is a complex process which involves balancing job-related factors such as location of the post, working conditions, and personal factors such as “fit” with a specialty or close proximity to family and friends1-4. There is increasing evidence that prior workplace experiences are important in careers decision-making5, most obviously in terms of a clear relationship between exposure to a specialty and later preference for that speciality6-8. Contemporary evidence suggests that early career doctors also draw on prior experience of the


BMJ Open

supportive culture, or not, of a unit/department/locality, to inform their careers decisions2,9. For example, evidence from countries including Germany, Netherlands, Australia, Finland, Canada, and the United States indicates that residents/trainees who experience a positive working culture (characterised by, for example, high quality training, and work-related social support) are less likely to have intentions to quit medical training or to wish to move into medical jobs without patient contact1,10,11. In our own context, the UK, there is a recent pattern of a large proportion of early career doctors not applying for specialty training at the time when they become eligible to do so.

Fo

Instead, approximately 50% of doctors at this stage are taking time out of the training system. The majority of those who take time out of training continue to work in the NHS but in service posts

rp

(posts that are not part of a training programme towards a particular specialty). Why this trend has

ee

become more obvious in recent years is of considerable interest to NHS employers, institutions responsible for medical education and training as well as researchers.

rr

Recent studies suggest that the wish to quit or at take time out of medical training may be related,

ev

at least in part, to a strong desire for supportive working and learning environments4,12,13.

iew

Foundation Year 2 (FP2) doctors who experience pressurised working environments with poor autonomy over their personal and work life report reductions in morale and motivation, and feelings of dehumanisation. However, the nature of this previous research - predominantly survey-

on

based10,11,14,15 or descriptive qualitative inquiry12– means we do not have a good understanding of

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 4 of 44

what a supportive culture means to early career doctors. Nor do we know how their perceptions of support or sources of dissatisfaction may impact on their career decision making. It is critical to explore these issues in detail as identifying ways to increase satisfaction with medical training may help stem issues with uneven distribution of doctors in terms of specialty and location16-19 and help attract sufficient doctors to apply for training posts, and hence meet anticipated immediate and future healthcare needs20,21.


Page 5 of 44

Our aim in this study was to explore FP2 doctors’ work-related experiences in relation to work-place support, and how this may have influenced their careers intentions. To extend understanding of this phenomenon and bearing in mind that using orienting concepts derived from social theory can enhance knowledge, understanding and interpretations that might not be identified using inductive approaches22, we used the theory of Perceived Organizational Support (POS)23,24 as a theoretical framework to aid conceptual generalizability and to highlight possible ways forward for medical education and employment policy and practice.

iew

ev

rr

ee

rp

Fo ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Methods Conceptual Framework Perceived organizational support (POS) is the relationship resulting from the reciprocal exchanges25 between an employee and the organisation23. POS relates to an individual’s perception of whether the organization values their work contributions and cares about their well-being23,24. Where employees perceive that the organization values and supports them, they will develop greater emotional attachment, engagement 26,27 and feelings of obligation to the organization28,29. This, in

Fo

turn, is positively related to a range of employee behaviours30,31 including intention to stay with the

rp

organization32-34, job satisfaction31,35, dedication34,36 and commitment to the organisations goals15,29,36. Commitment

rr

ee

POS suggests that reciprocity between employee and organisation can be expressed and evaluated

ev

as three, inter-related types of commitment: affective, normative and continuance (see Figure 1).

iew

Affective commitment refers to an individual’s emotional attachment to the organisation and is linked to the individual and the organisation’s goals, values and norms being similar, or in alignment33. If an individual has a high level of affective commitment to the organisation then they

on

are more likely to be satisfied with their job and may be more likely to stay with that organisation31,34,36,37.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 6 of 44

Normative commitment is the level of obligation and sense of loyalty an employee feels towards the organisation. This is related to individuals feeling acknowledged and rewarded by (via, for example, promotions, incentives28,38, and hence indebted to, the organisation which again may be demonstrated by wishing staying in the employment of that organisation. In other words, if an individual feels their organisation has shown commitment to them, they are more likely to show commitment to the organisation– and vice-versa33,34.


Page 7 of 44

The third and final level of commitment is continuance commitment. This is associated with employees evaluating the advantages and disadvantages of continuing to work for the organisation verses leaving the organisation14,31. Are they guaranteed better opportunities somewhere else, or are there too many risks associated with leaving? The three levels of commitment are not separate entities. Rather they overlap and link with one another. For example, if an individual develops an emotional attachment and dedication to the organisation (affective commitment), and the organisation has recognised and rewarded their

Fo

efforts, they may have a sense of loyalty to the organisation (normative commitment), and not wish

rp

to leave (continuance commitment) (see figure one). The role of others

ee

An important concept in POS is that any actions undertaken by other people within the organisation

rr

are perceived by the employees as acts of the organisation rather than the individual32,39 (see figure

ev

one). Perceived supervisory support (PSS)40: is an indicator of how much the organisation values the individual, and the personification of the organisation in this way leads to employees interpreting

iew

the actions of those more senior to themselves as reflecting the norms or the values of the organisation. Where individuals do not feel fairly treated or supported by senior staff, their sense of

on

attachment and obligation to the organisation decrease, and their inclination to leave (turnover intention) increases29. On the other hand, high levels of PSS - enacted via, for example, autonomy,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

participation in decision making, professional development opportunities, rewards and praise1,10,34 – may support an employee’s job satisfaction, emotional attachment, obligation and intent to stay with an organization34,37,41,42. Employees also evaluate the behaviour of team members and colleagues as personifying organisational norms and values, with the same outcomes in terms of organisational commitment as observed with senior staff28. Positive relationships with colleagues and team members are also important in another respect. These interpersonal relationships offer information about how to 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

become a successful organization member, as well as provide friendships that make work-life more pleasant15,33,43. Having role models, support and praise from more established colleagues positively affects the organisational commitment of newcomers into an organisation 41,9,44. POS has been used to explain performance, work-related stress, intentions to leave, organisational commitment and job satisfaction across a range of commercial and healthcare settings15,28,33,41,,44.

iew

ev

rr

ee

rp

Fo ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 8 of 44


Page 9 of 44

*****Figure one about here*****

ee

rp

Fo Methods

rr

Design

ev

In line with our worldview is that meaning is constructed through social interaction, this research is epistemologically grounded in social constructionism45,46. We used individual interviews to collect

iew

multiple perspectives and interpretations of reality in relation to the research question. Sampling and recruitment

on

Our target group was Foundation Programme doctors in the UK. After graduating from medical

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

school, UK doctors work in Foundation Programmes (FP) for two years full-time or the equivalent part-time. The FP is designed to ensure broad based training across the breadth of specialties with compulsory surgery, medicine and a “community” placement (e.g., general (family) practice, mental health). It aims to develop the clinical and professional skills of medical graduates, so they are prepared to progress into one of the range of speciality training pathways at the end of year two of the FP (FP2). The first opportunity for application for a specialty training post is in mid FP2, and traditionally most doctors applied at this stage of their career. However, things have changed in the


BMJ Open

last five years or so: only about half of FP2 doctors now apply for speciality or core training19. The others typically either take up a service post as mentioned earlier, work overseas for a period of time, or leave the profession. The organisation of UK medical training means that this change in careers-related behaviour leaves many unfilled posts, insufficient doctors to meet immediate healthcare needs and a potential shortfall of specialty-trained doctors in the longer term20,21. Upon receiving ethical approval and appropriate institutional consents (see later), FP2 doctors from two of the five Scottish FP regions were invited to participate in individual interviews. These regions

Fo

are diverse in terms of size and geographical locality, and because local data indicates that they

rp

attract different groups of FP doctors in terms of home origin and medical school attended. Foundation Programme coordinators from the two regions sent out an email giving details of the

ee

study and the researcher’s contact details to the 2015-2016 cohort of FP2 doctors. Those who were

rr

interested in taking part in the study were asked to contact the main researcher directly, by email.

ev

Those who did so were provided with more information about the study and invited to take part. Data collection

iew

This was a qualitative study using semi-structured interviews incorporating a narrative inquiry approach for data collection47. The interview schedules explored FP2 doctor’s experiences of their

on

postgraduate training and how this influenced their career intentions. The interview questions were

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 10 of 44

developed by drawing on the broad literature on medical careers decision making, particularly contemporary papers from the UK context2-4,9. We also drew on discussions on this topic arising in formal teaching sessions with FP doctors in the 12 months prior to data collection. The questions were piloted with a small group of volunteer FP doctors who did not take part in the main study. Our approach was iterative: we used our notes and recordings from early interviews to inform the development of additional questions for later interviews. The interview schedule is available on request.


Page 11 of 44

In order to elicit as broad a range of understandings as possible, maximum variation sampling was used to ensure diversity in terms of gender, graduate entry or school-leaving status as a medical student, ethnicity, location, and whether or not the individual had applied for a training post in FP2 or not. Individual interviews were carried out at times and places convenient for participants. Participants were provided with refreshments but no other incentives for taking part. At the end of each interview, participants were thanked for taking part. Data Analysis

Fo

All interviews were audio recorded with participant permission, transcribed for analysis, and entered

rp

on to NVIVO PRO 11 qualitative data management software. Familiarisation and data checking were achieved by listening to audio-recordings while reading transcripts. Thoughts and insights were

ee

recorded as a memo file for each doctor. Initial data coding and analysis was inductive, using

rr

thematic analysis to generate a coding scheme48. Analysis progressed via regular team meetings,

ev

where ongoing coding and comparisons were explored. Comparisons were made between codes and participants to explore differences and similarities in participants’ perspectives. Any discrepancies

iew

were discussed and then agreed upon. Analytical ideas and discussions were documented through memos and team correspondence that created an audit trail of the analytic process.

on

On scrutinising the themes in the data, we were struck that many of these seemed to relate to the relationships our participants had with the organisation in which they worked, and the people they

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

worked with. It was this that led us to use the theory of Perceived Organisational Support 24,26,27 (See earlier) to help understand and explain the data identify important factors and their potential relationships. Rigour was ensured in several ways49. All interviews were undertaken by the first author (GS) to ensure continuity. We considered our positions and relationships with the data continually and critically50,51 in view of our different disciplinary backgrounds (psychology; medicine), different levels of knowledge and experience of delivering and managing medical education and training, and 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

research perspectives and preferences. We constantly reflected on how these might have shaped our co-construction of the data. Preliminary data analysis was shared and discussed with colleagues outside the research team to explore if the findings seemed credible and reasonable52. Ethical approvals This study was granted ethical approval from the host university’s Ethics Research Board. This was accepted as evidence of ethical approval by the second site’s equivalent board. Approval and permission to carry out the study were also obtained formally from the relevant NHS (National

Fo

Health Services) Research and Development (R&D) departments. Written consent was obtained from all participants.

iew

ev

rr

ee

rp ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 12 of 44


Page 13 of 44

Results Twenty-three FP2 doctors expressed an interest in study participation. Two were not available for interview during the period of the study (January to April 2016). Of the 21 who participated: eight were from Region A and 13 from (the larger) Region B; 13 were female, eight male; 17 had entered medical school directly from high school (the norm in the UK) while four were graduate entrants; 13 were born and raised in Scotland, six were born and raised elsewhere in the UK and two were from mainland Europe. Of those interviewed, 11 had applied for specialty or core training in FP2.

Fo

The median interview length of interviews was 30.26 minutes (from 18 minutes to 52 minutes).

rp

Our initial framework analysis identified the main themes captured in the data from across the

ee

participant group. These were: positive supervisory support, poor supervisory support, team environment, and feeling valued. We then used the POS theory to interpret and organise the data.

rr

This worked effectively yet we felt that presenting the data thematically failed to illustrate the

ev

critical experiences of our participants53,54. Instead, and with reference to Kendall and Kendall’s (2012)55 view that ‘the whole story is greater than the sum of its parts’ (p.179), we present the data

iew

as the stories told by participants to the researcher56. This allowed us to explore the multiple dynamics of workforce relationships and experiences, and related decision making57. We chose five

on

stories that exemplified the main themes well, where participants lay out how they experienced certain events and conferred their subjective meaning onto these experiences.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

We provide personal background characteristics for each story told58, to give the reader a deeper knowledge and understanding of each person’s story55. We present participant’s key stories in their own words59.


BMJ Open

Story 1: ‘I think senior support at time was a huge factor for us…’ In this first story (see box 1), Daniel (please note all names are pseudonyms) is a 25-year-old male foundation doctor. He is originally from Northern Ireland but came to Scotland for medical school and stayed on to do the FP. Some members of Daniel’s family had worked in the healthcare sector although not directly in medicine. He worked in various part-time and volunteer jobs during his medical degree. Daniel lives with his long-term girlfriend who is also a foundation doctor. Daniel had a particularly positive experience throughout his time on the foundation programme, the most

Fo

noteworthy experience for him was his experience in his A&E rotation. In Box one we see clear

rp

examples of how feeling supported and feeling valued played a key role in influencing Daniel’s decision to apply for speciality training.

rr

ee …………… Box 1 about here…………..

iew

ev In this story we can identify that Daniel’s experience of a positive working culture impacts both his commitment to the organization and the perception of support that would be available in the future. This is evidenced when Daniel explains that he is has applied for Anaesthetics specialty training and

on

indicates one reason for applying is related to the level of support that he will gain in this particular

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 14 of 44

specialty (lines 18-22). We can infer from Daniel’s story that, for him, a supportive working environment is based on a culture that is enriched with ‘enthusiastic’ supervisors who are willing to ‘take an interest’ in the professional careers of FP2 doctors and that helps to really ‘make it’ an enjoyable experience (lines 9-13). Daniel’s story has emotional elements to, in that he describes ‘feeling valued’, and this influences his commitment to the organisation and motivates him to apply for anaesthetics (lines 9-10).


Page 15 of 44

In terms of POS theory, Daniel may attribute the acts undertaken by his supervisor as evidence of the level of investment and value the organization places on his personal and professional development15,32. The level of investment that the senior member of staff demonstrated in Daniels A&E rotation helped to convey the future behaviours that would be present in the NHS which enabled him to recognise attributes of supervisors which would enhance his own future working conditions and made him feel more invested in a specialty that offers a high level of ‘one-on-one’ training with seniors. Overall, this story illustrated the key influence a positive clinical supervisor-

Fo

employee relationship can have on an early career doctors intentions to stay working in the NHS.

rp

Story 2- ‘Having done that, I knew that was what I wanted to do and so I applied…’

ee

In this second story, Steven is a 26-year-old male foundation doctor. He is originally from England

rr

and did his medical degree there as a graduate entrant. He moved to Scotland for the FP. He worked

ev

part-time throughout both his degrees. He comes from a non-medical family and a working-class background. Steven had a girlfriend from Scotland who was pursuing a non-medical degree within

iew

Scotland. Steven explains a critical point in his F2 programme which helped him develop sufficient confidence to apply for speciality training (Box 2).

**********Box 2 about here*********

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Steven’s story highlights the importance of having seniors who want their junior members of staff to flourish in their working environment. He remarks he could have ‘easily been given rubbish tasks to do’ but instead received good training opportunities (lines 1-2). From the very beginning of his FP2 Steven feels like a valued member of the team and that seniors are eager for him to learn on the job.


BMJ Open

The timing of his anaesthetics rotation was critical. Steven reflects that without the direct experience of working in anaesthetics and being able to compare it with his other FY experiences, he would have not known that this specialty would “fit” him in terms of his personality and what he enjoyed in the workplace (lines 6-9, lines 16-19). Having the support from ‘different consultants’ played a critical role in Steven applying for acute care common stem training programme (two-year programme which covers acute specialities including anaesthesia, emergency medicine, acute medicine and intensive care) (lines 20-22, lines

Fo

26-28). The level of commitment that was shown by the seniors was perhaps a direct indicator to

rp

Steven that his professional development and well-being would be looked after if he trained in anaesthetics within the NHS (lines 40-41).

ee

Viewed through the POS lens, it seems that Steven’s level of obligation to the organisation28,29. It

rr

seems that Steven’s level of obligation was influenced by both feeling valued34 and perceiving that

ev

senior members of staff had invested a great amount of time and energy to ensure that he gained important opportunities prior to applying for speciality training15. These positive encounters seemed

iew

to influence his intentions to not take a year out of training but to apply for specialty training in FY2.

on

Story 3: ‘I really, really wanted to do it. I’ve always wanted to be a doctor. And I got here, and I’ve

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 16 of 44

just found it devastating’

In this third story, Abigail is a 25-year-old female FP2 doctor. She is originally from England, and did her medical degree there before moving to Scotland for the FP. The FP was her first experience of working life. She comes from an affluent, medical family background. She is single and living alone. The FP was not a positive experience for her and she did not apply for specialty training (Box 3).

****Box 3 about here**** 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 17 of 44

Abigail reflects that she found the foundation programme disappointing on a personal and professional level, which ultimately affected her morale and commitment to the NHS (lines 1-2). Abigail goes on to highlight how she was ‘very’ disheartened by the NHS and never expected to be ‘treated so badly as a professional’. She expressed feeling mistreated and not feeling welcomed by team members (lines 5-11, lines 17-18). This perceived lack of support during her FP ultimately deterred Abigail from the ‘profession as a whole’ (lines 24-25).

Fo

When evaluating Abigail’s story, we can extrapolate that she feels like the NHS does not value or

rp

care about the well-being of their junior doctors. This would fit with one important concept of POS: that employees assign human like characteristics to the organisation they work for24,26,27. For Abigail,

ee

the poor treatment she receives from members of her immediate team exemplifies to her the way

rr

the whole NHS works. Thus, supervisors and established team members not treating juniors fairly

ev

can lead to low affective commitment, ultimately leading to higher turnover intentions (and conversely the research has shown this evidence: Otto & Mamatoglu, 201537; Rhoades et al., 200127; Malik et al., 201614).

iew on

Story 4- ‘And at the end of that, I thought, no, I don’t want to. I decided to take a year out from that’.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

This fourth story was from Gemma, a 25-year-old Female Foundation Doctor, originally from Wales, where she completed medical school. She moved to Scotland for the FP. She is single, and all her family and friends still live in Wales. She comes from a non-medical family but has family members who were healthcare professionals. Gemma had experience of doing some charity and voluntary work throughout her degree. Box 4, explains a critical experience Gemma had in her paediatrics


BMJ Open

rotation and how this incident had a detrimental impact on her intention to apply for training and instead opt to take a break.

****Box 4 about here****

Gemma reflects that she found it ‘a bit overwhelming and exhausting’ when senior staff were not

Fo

available to help or support her. She describes a critical incident that involves a death of an infant

rp

baby and how she is blamed for this afterwards (lines 12- 16). The most difficult factor for Gemma is that she is not ‘debriefed or supported through this’ and leaves her feeling responsible for a child’s

ee

death (lines 17-19). This specific incident not only affected Gemma at personal level but also at a professional level as it was at end of that rotation that she ‘decided to take a year out from that’.

rr

From a POS perspective, Gemma did not experience a sense of emotional (affective) commitment

ev

from her senior members of staff at a critical time. She did not feel like the NHS cared and respected

iew

her at a professional or personal level. We can infer from Gemma’s story that positive relationships with senior staff not only increase the perception of support, but they also seem to act as a buffer which helps more junior doctors to cope with challenging situations15,37,41,60. Where this is lacking,

on

emotional obligation to the organisation is affected, which can impact on turnover intentions (as per Gemma deciding not to apply for specialty training28,29,34.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 18 of 44

Story 5: ‘Management don’t know who I am… I think they see that you’re a hassle… as opposed to, you’re a valued team member…’ The final story is told by Clare. She is from Scotland where she completed her medical degree as a graduate, before doing her FP in Scotland. She worked before and during medical school. She comes from a non-medical family and her fiancée is non-medical. She plans to start a family within 18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 19 of 44

the next few years. Clare shares many challenges she experienced throughout her foundation programme in both her professional and personal life. In Box 5, she highlights a particular incident that occurred that put her off working in hospital medicine.

****Box 5 about here**** Clare reflects that her personal life is not something that is valued by the healthcare team and not

Fo

being able to control her working hours is a source of frustration (lines 5-8). There is a sense that her annual leave is not something that is respected or valued by the management and that when Clare

rp

queries this she is deemed ‘a problem’ (lines 2-4, lines 30-32).

ee

Clare describes a critical experience in her neurosurgery rotation in which she felt under supported and highlights she was ‘put into horrific, horrific situations’ (lines 21-24). This negative experience

rr

had a lasting impact and was influential in terms of putting Clare off working in the hospital in which

ev

she completed her F2 training: there is ‘literally no way’ she would work in that hospital again (lines

iew

27-29).

From a POS perspective feeling valued by the organisation is a strong motivator for participants to stay invested in that organisation, and vice-versa (as was the case for Clare). Lack of appreciation of

on

her personal needs (annual leave requests) led to her disengagement and reduced commitment

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

towards working in that hospital ever again (continuance commitment: Eisenberger & Stinglhamber, 201141; Rhoades & Eisenberger, 200227; Allen et al., 200333; Kaplan et al., 201235). Instead, Clare opts to apply for GP training, perhaps perceiving that this will provide better working conditions which will illustrate that she is valued and an important member of the team.

Common themes


BMJ Open

We also looked to identify any overlapping patterns across data which were exemplified in the five stories61. Daniel and Steven were afforded opportunities to engage with several senior staff on a regular basis, their working environments were supportive, and they gained exposure to specialities prior to applying for specialty training. On the other hand, Gemma and Abigail had very negative experiences of the foundation programme and developed a negative personification of the organization as a whole with a particular focus on a lack of support from team members. A lack of support during time critical situations was enough to put Clare off working in a specific hospital

Fo

again and enough to put Gemma off applying for training at completion of FP2. The data suggests that support, encouragement and feeling valued underpin organisational commitment and turnover

rp

intention in FP doctors.

iew

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 20 of 44


Page 21 of 44

Discussion To the best of our knowledge, this is the first study to explore what a supportive culture means to early career doctors, and how perceptions of support may influence career decision making. The data indicated that support from supervisors/senior colleagues and team members influenced organisational engagement. Having positive relationships with other staff increased the perception of a supportive culture but also seemed to act as a safeguard when challenging situations arose. The opposite was also true. Those who perceived poor senior and/or team support tended to have a

Fo

negative personification of the organisation and had higher intentions to leave the NHS or opt to

rp

work in a different speciality. In short, the behaviour of people within the organisation was an indicator of whether or not the NHS cared and respected the individual as a member of the organisation.

rr

ee

Our findings align with the wider organisational literature. For example, having a high level of

ev

support from supervisors or more senior colleagues (Perceived Supervisory Support: PSS: see earlier) can lead to increased loyalty in the workplace62, better job performance63 and increases in

iew

psychological well-being64, as well as having a positive impact on employee retention40,65,43. Indeed, PSS is becoming one of the most influential factors in predicting turnover intention: the less support

on

from a supervisor, the more likely the employees are to leave the organisation (or specialty), and vice-versa32. However, the POS theory may have limitations in contexts such as the UK, where there

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

is only one healthcare training provider, the National Health Service (NHS). In such “monopoly” situations, there may be a less obvious relationship between continuance commitment and turnover intentions14. On the other hand, doctors in training can still “vote with their feet” by applying to train in a different speciality or region, take a break from training, or move overseas to seek better opportunities. This represents early career doctors are taking responsible for their own career development. That they are doing so in a different way from what is expected by the training system


BMJ Open

structure, which is perfectly reasonable from an individual perspective- but is an issue for the system where trainees are integral to service delivery. While perceptions of support varied, our data also suggested that there were differences in how participants engaged with their working environments. Different FP2 doctors interpreted what seemed to us as reasonably similar situations in different ways: as either an opportunity (to work independently) or, conversely, as a situation where they felt unsupported. This fits with theories which conceptualise learning through work as a relational interdependence of affordances

Fo

(opportunities) and the readiness of the individual to engage with these opportunities (i.e. how

rp

individuals respond to what is offered in the workplace)66. For example, one relevant factor seemed to be prior work experience. For some participants this was their first work experience. Others had

ee

held many part-time jobs while at university. The data hinted at this personal factor shaping

rr

participants’ interpretations of experiences. This requires further independent investigation and in terms of how seniors can supportively manage trainees’ expectations to mitigate stressors.

iew

ev

We started our study without preconceptions of what we might find. The choice of theory was decided by the data when we realised that social relationships and organizational culture were key

on

elements in our participants’ stories. Interestingly, the main theoretical frameworks used in studies of work-based medical training are socio-cultural views on learning67,68. Our data directed us to

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 22 of 44

organizational theory, thus providing a fresh perspective on a well-acknowledged issue and responded to calls in the literature to focus on the organisational context of postgraduate training6870

. The use of a theoretical lens also allowed us to progress from knowledge gathered from previous

a-theoretic studies on this topic26,41, to provide thick description71 and conceptual generalisability72, both of which are important in qualitative research22. Any one conceptual lens can only highlight or illuminate certain aspects of the data73 and another lens may have highlighted other elements of the issue under focus. For example, we focused on what was said not how it was said61,74. A useful


Page 23 of 44

secondary analysis of the data might explore the particular linguistic methods used by FP2 doctors when describing critical workplace experiences and how these influenced their career decisionmaking75,76. We presented doctors’ experiences as short stories in order to capture meaning and understanding in the data and ultimately not to lose key elements of participant experiences. Stories can convey the experience of one individual and make it resonate with others47. Through our analytical process we took care to ensure to share our participants’ stories in such a way that they convey meaning and

Fo

purpose to the reader61,77. While some researchers quantify qualitative data to highlight patterns

rp

within the data (e.g., Schiffrin 1994)78 we did not do so, instead maintaining a purely qualitative approach. As mentioned earlier, we could have presented the data as themes, with supporting

ee

quotes from a wider number of participants. We tried this, but in our view, this way of presenting

rr

the data did not illuminate clearly the relationships between experiences, perceptions of support and how these influenced their career decision-making.

ev

We interviewed F2 doctors in two regions of Scotland and took care to recruit a diverse sample,

iew

representing doctors of both genders, graduate and school leaver (undergraduates) entrants to medical school, and a mix of doctors from across the UK and Europe, which would be representative and consistent of junior doctors working in the NHS19. However, their views may not be

on

representative of all FP doctors across the UK – a larger scale study may be useful to explore this further.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Our findings have implications for policy and practice. We have identified the critical importance of support and feeling valued in F2 doctor’s career intentions. We can infer from the literature that positive social relationships with colleagues79,80, intrinsic motivation81, self-efficacy in one’s skills and abilities79,82 and early exposure to training opportunities that were positively encouraged by senior medical staff5 are important components in terms of committing to further medical training (i.e. applying for speciality training). This reinforces the importance of a supportive clinical learning and


BMJ Open

working environment, a factor which has been recently highlighted in the General Medical Council’s (GMC) most recent document on the state of medical education and training in the UK83. Yet, on the other hand, the data also suggests that there is an interaction between individual and the workplace environment. This duality merits further investigation. What our study has added is more insight into the important role played by senior staff and team members in terms of exemplifying the culture of the organisation and behavioural norms in terms of how people are treated by the organisation37. Colleagues can therefore help to improve junior

Fo

doctors’ perceptions of organisational support through prosocial behaviours like allowing trainee

rp

doctors more autonomy, participation in decision making, offering opportunities in professional development, offering rewards and praise for good work1,10,33. This may not always be easy where

ee

training competes with service in pressured environments where time and resources are limited83-86.

rr

However, creating positive working environments does not need to be complicated: consultants and colleagues knowing the name of their trainee is a simple way to ensure workers feel valued87. The

ev

norm of reciprocity states that members who feel cared for and supported by the organisation will

iew

reciprocate these same patterns of behaviour in return to the organisation25. In other words, treat your juniors well and they will be happier and more committed to the NHS34,37,41. This simple rule of behaviour may go some way to encouraging junior doctors to stay in the training pipeline.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 24 of 44


Page 25 of 44

iew

ev

rr

ee

rp

Fo ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Contributions JC, PJ and KW obtained the funding for GS’s doctorate. The development of the interviews was led by GS in collaboration with JC. GS prepared the ethics application. GS lead on the literature review. JC supervised the analysis, which was carried out by GS with input from PJ and KW. GS drafted the paper, with JC extensively revising drafts for each section of the paper. All authors contributed to the final paper. The study is guaranteed by the University of Aberdeen. Collaborator Statement

Fo

This project is in collaboration with NHS Education for Scotland. Ethical permission

ee

rp

Ethical permission was granted for this study from the University of Aberdeen College of Life Sciences and Medicine Ethics Research Board (CERB/2015/12/1269, approval granted 25/01/16).

rr

Funding

ev

Our thanks go to NHS Education for Scotland for funding Gillian Scanlan’s programme of work

iew

through the Scottish Medical Education Research Consortium (SMERC) and for funding the open access fee for this paper. Competing Interests

ly

The authors declare no competing interests.

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 26 of 44

Data Sharing All available data can be obtained by contacting the corresponding author (Gillian Scanlan). Acknowledgements Our thanks to all those FP2 doctors who participated in the interviews. Our thanks also to the Foundation Programme Directorate staff in the Scotland Deanery, NHS Education for Scotland for sending out the email correspondence to the two regions involved in the interviews. 26 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 27 of 44

References 1. Degen C, Weigl M, Glaser J, Li J & Angerer P. The impact of training and working conditions on junior doctors’ intention to leave clinical practice. BMC Medical Education 2014, 14:119. 2. Scanlan G, Cleland J, Johnston P, Walker K, Krucien K, Skatun D. What Factors Are Critical to

Fo

Attracting NHS Foundation Doctors into Speciality or Core Training? A Discrete Choice

rp

Experiment. 2018 (BMJ Open in press)

ee

3. Cleland J, Johnston PW, Watson V, Krucien, N, Skatun D. What do UK doctors in training

rr

value in a post? A discrete choice experiment. Med Educ. 2016; 50: 189-202.

ev

4. Cleland JA, Johnston P, Watson V, Krucien, N, Skatun D. What do UK medical students value most in their career? A discrete choice experiment. Med Educ. 2017; doi:10.1111/medu.13257.

iew

5. Pianosi K, Bethune C, Hurley KF. Medical student career choice: a qualitative study of fourth-

on

year medical students at Memorial University, Newfoundland. CMAJ Open. 2016; 4 (2).

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

6. Maertz CP & Griffeth, R.W.“Eight motivational forces and voluntary turnover: a theoretical synthesis with implications for research”, Journal of Management, 2004; Vol. 30 No. 5, pp. 667-683.

7. Deutsch T, Honigschmid P, Frese T, Sandholzer H. Early community-based family practice elective positively influences medical students’ career considerations – a pre–postcomparison. BMC Fam Pract 2013;14:24. 27 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

8. Akhund S, Shaikh ZA, Kolachi HB. Career related choices of medical students from an International Medical College of Karachi, Pakistan. JLUMHS 2012;11:03. 9. Lachish S, Goldacre MJ, Lambert T. Associations between institutional support, job enjoyment, and attitudes to work in first-year doctors in the UK: national questionnaire survey. BMC Med Educ. 2016; 16:151.

10. Boerjan M, Bluyssen SJM, Bleichrodt RP, Van Weel-Baumgarten EM,Van Goor H: Work-

Fo

related health complaints in surgical residents and the influence of social support and job-

rp

related autonomy. Med Educ 2010, 44(8):835–844.

rr

ee 11. Ochsmann EB. Thinking About Giving Up Clinical Practice? A Gender-Stratified Approach to Understanding Junior Doctors' Choices. Academic Medicine 2012, 87(1):91–97.

iew

ev

12. Rich A, Viney R, Needleman S, Griffin A, Woolf K. You can’t be a person and a doctor’: the work-life balance of doctors in training- a qualitative study. BMJ Open. 2016; 6 :e013897

on

13. Spooner S, Gibson J, Rigby D, Sutton M, Pearson E, Checkland K. Stick or Twist? Career

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 28 of 44

decision-making during contractual uncertainty for NHS Junior Doctors. BMJ Open. 2017;7: e013756.

14. Malik SZ, Kazmi SZ, & Nadeem N. The Effect of Perceived Organizational Support on Doctors’ Organizational Commitment in Pakistan. The Lahore Journal of Business, 2016; 4(2), 73–92.


Page 29 of 44

15. Madden L, Mathia BD & Madden TM. In good company: The impact of perceived organizational support and positive relationships at work on turnover intentions. Management Research Review, 2015; 38 (3).

16. Frechette D, Hollenberg D, Shrichand A, Jacob C,Datta I. What’s Really Behind Canada’s Unemployed Specialists? Too Many, Too Few Doctors? Findings From the Royal College’s

Fo

Employment Study. Ottawa, ON:Royal College of Physicians and Surgeons of Canada 2013

rp

17. Gorman DF, Brooks PM. On solutions to doctor shortages in Australia and New Zealand. Med

ee

J Aust,2009;190 (3):152–6.

rr

18. Patty A. Forecast oversupply of doctors to hit this year amid calls to halt imports. Sydney Morning Herald.http://www.theage.com.au/business/workplace-relations/forecast-

ev

oversupply-of-doctors-to-hit-this-year-amid-calls-to-halt-imports-20170103-gtle76. [Accessed11 June 2017.]

iew

19. UKFPO CAREER DESTINATION REPORT 2016

on

www.foundationprogramme.nhs.uk/download.asp?file=Careers_destination_2016.pdf (accessed 8th of March 2017).

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

20. Gorman DF. Planning healthcare workforces for uncertain futures. Acad Med 2015;90 (4):400–3. 21. Addicott R, Maguire D, Honeyman M, Jabbal J. Workforce planning in the NHS. The King’s Fund. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforceplanning-NHS-Kings-Fund-Apr-15.pdf. [Accessed 1 August 2016.] 22. Layder D. New Strategies in Social Research: An Introduction and Guide. London: Sage;1998.


BMJ Open

23. Eisenberger R, Huntington R, Hutchison S, & Sowa D. Perceived organizational support. Journal of Applied Psychology, 1986; 71(3), 500–507. 24. Eisenberger R, Armeli S, Rexwinkel B, Lynch PD, & Rhoades L. Reciprocation of perceived organizational support. Journal of Applied Psychology, 2001; 86(1), 42–51. 25. Gouldner AW. The norm of reciprocity: A preliminary statement. American Sociological Review, 1960; 25(2), 161–178.

Fo

26. Rhoades L, Eisenberger R, & Armeli S. Affective commitment to the organization: The

rp

contribution of perceived organizational support. Journal of Applied Psychology, 2001; 86(5), 825–836.

rr

ee

27. Rhoades L, & Eisenberger R. Perceived organizational support: A review of the literature.

ev

Journal of Applied Psychology, 2002; 87(4), 698–714.

iew

28. Kurtessis JN, Eisenberger R, Ford MT, Buffardi LC, Stewart KA, Adis CS. Perceived Organizational Support: A Meta-Analytic Evaluation of Organizational Support Theory. Journal of Management, 2015; Vol. 43, issue 6, 1854–1884

on

29. Newman A, Thanacoody R, & Hui W. The effects of perceived organizational support,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 30 of 44

perceived supervisor support and intra-organizational network resources on turnover intentions: A study of Chinese employees in multinational enterprises. Personnel Review, 2012; 41(1), 56-72. 30. Hao J, Wang J, Liu L, Wu W & Wu H. Perceived Organizational Support Impacts on the Associations of Work-Family Conflict or Family-Work Conflict with Depressive Symptoms among Chinese Doctors. International Journal of Environmental Research and Public Health, 2016; 13, 326.


Page 31 of 44

31. Tekingündüz S, Top M, Tengilimoğlu D & Karabulut E. Effect of organisational trust, job satisfaction, individual variables on the organisational commitment in healthcare services. Total Quality Management & Business Excellence, 2017; 1478-3371. 32. Maertz CP, Griffeth RW, Campbell NS, & Allen DG. The effects of perceived organizational support and perceived supervisor support on employee turnover. Journal of Organizational Behavior, 2007; 28(8), 1059–1075. 33. Allen D, Shore L & Griffeth R. “The role of perceived organizational support and supportive

Fo

human resource practices in the turnover process”, Journal of Management, 2003; 29(1), 99118.

ee

rp

34. Allen DG & Shanock LR. “Perceived organizational support and embeddedness as key mechanisms connecting socialization tactics to commitment and turnover among new

rr

employees”, Journal of Organizational Behavior, 2013; 34(3), 350-369.

ev

35. Kaplan M, Ogut E, Kaplan A, & Aksay K. The relationship between job satisfaction and

iew

organizational commitment: The case of hospital employees. World Journal of Management, 2012; 4(1), 22–29.

on

36. Arshadi N. The relationships of perceived organizational support (POS) with organizational

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

commitment, in-role performance and turnover intention: Mediating role of felt obligation. Procedia – Social and Behavioral Sciences, 2011; 30, 1103–1108.

37. Otto K & Mamatoglu N. Why Does Interactional Justice Promote Organizational Loyalty, Job Performance, and Prevent Mental Impairment? The Role of Social Support and Social Stressors, The Journal of Psychology, 2015; 149:2, 193-218.


BMJ Open

38. Allen N.J & Meyer J.P. The measurement and antecedents of affective, continuance, and normative commitment to the organization. Journal of Occupational Psychology, 1990 63, 1– 18. 39. Levinson H. “Reciprocation: the relationship between man and organization”, Administrative Science Quarterly, 1965; Vol. 9, pp. 370–390.

40. Kalidass A & Bahron A. The Relationship between Perceived Supervisor Support, Perceived

Fo

Organizational Support, Organizational Commitment and Employee Turnover Intention.

rp

International Journal of Business Administration, 2015; 6(5).

rr

ee 41. Eisenberger R & Stinglhamber F. Perceived Organizational Support: Fostering Enthusiastic and Productive Employees, American Psychological Association, Washington, DC. 2011.

iew

ev

42. Buddeberg-Fischer B, Dietz C, Klaghofer R, Buddeberg C: Swiss residents' arguments for and against a career in medicine. BMC Health Serv Res, 2006; 6(1):98.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 32 of 44

43. Dutton J.E & Ragins BR. (Eds). Exploring Positive Relationships at Work: Building A Theoretical and Research foundation, Lawrence Erlbaum Associates, Mahwah, NJ. 2007.

44. Filipova AA. “Relationships among ethical climates, perceived organizational support, and intent-to-leave for licensed nurses in skilled nursing facilities”. Journal of Applied Gerontology, 2011; 30 (1), 44-66. 45. Crotty M. The Foundations of Social Research. 2003. Sage: London.


Page 33 of 44

46. Trần Văn Kham. Overview of Social Constructionism and Its Potential Applications for Social Work Education and Research in Vietnam. Journal of Social Sciences and Humanities, 2013; Vol. 29, No. 4, 30-37. 47. Bamburg M. Stories: Big or Small: Why do we care? Narrative Inquiry, 2006, 16 (1), 139-147. 48. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3 (2): 77-101.

Fo

49. King, N, Horrocks Ch. 2010. Interviews in Qualitative Research. London: Sage Publications

rp

50. Lincoln YS, Guba EG. Naturalistic Enquiry. 1985. Beverley Hills, CA: Sage. 51. McMillan W. Theory in healthcare education research: the importance of worldview. In:

ee

Cleland JA, Durning SJ, eds. Researching Medical Education. Oxford: Wiley 2015; 15-23.

rr

52. Varpio L, Ajjawi R, Monrouxe LV, O’Brien, Rees CE. Shedding the cobra effect:

ev

problematising thematic emergence, triangulation, saturation and member checking. Medical Education 2017; 51: 40-50

iew

53. Monrouxe L.V, Rees C.E, Lewis N.J, & Cleland J. Medical educators’ social acts of explaining passing underperformance in students: a qualitative study. Adv in Health Sci Educ, 2011, 16, 239-252.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

54. Dennis A.A, Foy M.J, Monrouxe L.V, & Rees C.E. Exploring trainer and trainee emotional talk in narrative about workplace-based feedback processes. Adv in Health Sci Educ, 2017, 23 (1), 75-93. 55. Kendall J.E, and Kendall K.E. STORYTELLING AS A QUALITATIVE METHOD FOR IS RESEARCH: HERALDING THE HEROIC AND ECHOING THE MYTHIC. Australasian Journal of Information Systems, 2012, Volume 17 (2). 56. Bruner J.S. (1990) Acts of Meaning, Harvard University Press, Cambridge, MA. 33 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

57. Frohman D. (2006) “Leadership Under Fire,” Harvard Business Review, Vol 84 No 12, 12, pp 124-131. 58. Flick U, Kardorff EV, & Steinke I. A companion to qualitative research. London: Sage. 2004. 59. Bamburg M, & Demuth C. Narrative Inquiry: An Interview with Michael Bamberg. Eur J Psychol, 2016, 12 (1), 14-28. 60. Stinglhamber F, & Vandenberghe C. Organizations and supervisors as sources of support and

Fo

targets of commitment: A longitudinal study. Journal of Organizational Behavior,2003; 24, 251-270.

rp

61. Bailey P.H & Tilley S. Storytelling and the interpretation of meaning in qualitative research.

ee

Journal of Advanced Nursing, 2002; 36 (8), 574-583.

rr

62. Sparr JL & Sonnentag S. Fairness perceptions of supervisor feedback, LMX, and employee well-being at work. European Journal of Work and Organizational Psychology, 2008; 17, 198–225.

iew

ev

63. Wang X, Liao J, Xia D, & Chang T. The impact of organizational justice on work performance: Mediating effects of organizational commitment and leader-member exchange.

on

International Journal of Manpower, 2010; 31, 660–677.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 34 of 44

64. Spell CS, & Arnold TJ. A multi-level analysis of organizational justice climate, structure, and employee mental health. Journal of Management, 2007;33, 724–751.


Page 35 of 44

65. Eisenberger R, Stinglhamber F, Vandenberghe C, Sucharski IL, & Rhoades L. Perceived supervisor support: Contributions to perceived organizational support and employee retention. Journal of Applied Psychology, 2002; 87(3), 565–573. 66. Billett, S 2001 Coparticipation at work: affordance and engagement. In fenwick T (ed) Sociocultural perspectives on learning through work (vol 92). Jossey Bass/Wiley, San Francisco. 67. Eraut M. Informal learning in the workplace. Stud Contin Educ. 2004;26(2):247-273.

Fo

68. Skipper M, Nøhr SB, Jacobsen TK, Musaeus P. “Organisation of workplace learning: a case

rp

study of paediatric residents’ and consultants’ beliefs and practices.” Adv Heal Sci Educ. 2015; 21:677–694.

ee

69. van de Wiel MWJ, Van den Bossche P, Janssen S, Jossberger H. Exploring deliberate practice

rr

in medicine: how do physicians learn in the workplace? Adv Health Sci Educ Theory Pract. 2011;16(1):81-95.

iew

ev

70. Sargeant J, Mann K, Sinclair D, et al. Learning in practice: experiences and perceptions of high scoring physicians. Acad Med. 2006;81(7):655-660.

on

71. Geertz C. The Interpretation of Cultures: Selected Essays. Fontana: London. 1993

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

72. Strauss A & Corbin J. Basics of Qualitative Research Techniques and Procedures for Developing Grounded Theory (2nd edition). Sage Publications: London. 1998

73. Bordage G. Conceptual frameworks to illuminate and magnify. Medical Education. 2009 43: 312-319.


BMJ Open

74. Reissman C.K. Narrative Analysis. In: Narrative, Memory & Everyday Life. University of Huddersfield, Huddersfield, 2005, pp 1-7. 75. Labov W, & Waletzky J. Narrative analysis. Essays on the Verbal and Visual Arts, Ed. J. Helm, 12-44. Seattle: U. of Washington Press. 1967 76. Labov W. Some further steps in narrative analysis. Journal of Narrative and Life History, 1997,7, 395-415.

Fo

77. Rooney T, Lawlor K, Rohan E “Telling Tales; Storytelling as a methodological approach in research”. The Electronic Journal of Business Research Methods 14 Issue 2 2016, (pp147-156

rp

78. Schiffrin, D. (1994). Approaches to discourse. Oxford: Blackwell.

ee

79. Bandura A. Cultivate self-efficacy for personal and organizational effectiveness. Oxford: Blackwell. 2000

ev

rr

80. Karademas EC. "Self-efficacy, social support and well-being. The mediating role of optimism". Personality and Individual Differences, 2006; 40, 1281-1290.

iew

81. Eisenberger R, Rhoades L & Cameron J. “Does pay for performance increase or decrease perceived self-determination and intrinsic motivation?”, Journal of Personality and Social Psychology, 1999; Vol. 77 No. 5, pp. 1026-1040.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 36 of 44

82. Lunenburg FC. Self-Efficacy in the Workplace: Implications for Motivation and Performance. International Journal of Management, Business, and Administration, 2011; 14,1. 83. General Medical Council (GMC). The state of medical education and practice in the UK. 2011. http://www.gmc-uk.org/State_of_medicine_Final_ web.pdf_44213427.pdf. [Accessed 28 August 2016.]


Page 37 of 44

84. Busari JO, Koot BG. Quality of clinical supervision as perceived by attending doctors in university and district teaching hospitals. Med Educ 2007;41(10):957–64. 85. Henning MA, Shulruf B, Hawken SJ, Pinnock R. Changing the learning environment: the medical student voice. Clin Teach 2011;8 (2):83–7. 86. Turner TL, Fielder E, Ward MA. Balancing service and education in residency training. A logical fallacy. JAMA Pediatr 2016;170 (2):101–2.

Fo

87. Cleland J, Roberts R, Kitto S, Strand P, & Johnston P. Using paradox theory to understand responses to tensions between service and training in general surgery. Medical Education,

rp

2017, doi: 10.1111/medu.13475.

iew

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Box 1- Daniel’s Story 1

I think senior support at times was a huge factor for us, particularly in A&E. I'm never on shift without somebody

2

who's at least a senior registrar or a consultant. So I've never, ever had any issues. Sometimes getting them it's a little bit difficult but it's just the nature of the job…they are probably seeing a patient, but I just go in and grab 4 them and call them out if I need 4them, you know. So if I need access to them. 3

5

When I went to A&E, my educational supervisor in A&E, she's very proactive. She's super. We did a lot of discussion around how I manage patients, so she'll call the patients up that I've seen X number of weeks ago, and 7 we go through and look at my documentation, see how I managed it. And it's not criticising me. I mean if it is 8 critical, it's constructive criticism. So I think that's a huge, huge aspect of learning as a junior. 6

9

And that's the first time I've had a supervisor that has been that enthusiastic, and that makes a hell of a difference … She even creates opportunities for you…. And then that leads into feeling valued’

10

Fo

11

SP1: Difference that you feel more supported I take it?

12

SP2: Yeah. She even creates opportunities for you. She'll go out of her way to sort things. I got a taster week in…Anaesthetics I got, long term advanced trauma life support. If they take an interest in you it makes it…

13 14 15

rp

SP1: So you've obviously mentioned getting; cracking on and getting on with it. So you've applied for speciality training or core medical training at FY2?

ee

16

SP2: Yes, I applied for anaesthetics.

17

SP1: Anaesthetics, okay. And why were you attracted to anaesthetics?

rr

18

SP2: I've done it and I liked it… When you see what they do and how they... How well-supported they are as a junior. So they're probably the best trained in terms of consultants with juniors. So you're one-on-one, junior 20 and consultant most of the time as an anaesthetic trainee. The training you get is... You know, they're able to 21 deal with nearly everything, in terms of managing patients. That's what attracted me to it as well is the quality of 22 training you're going to get.

19

iew

ev

23

SP1: The quality and the kind of support that you're getting as well?

24

SP2: Yes, exactly

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 38 of 44


Page 39 of 44

Box 2 Steven’s Story 1

…when I got out I was actually doing the job because I could have easily just been given rubbish tasks to do for 4 months but I was encouraged to take part and work with a wide variety of consultants, see 3 how they worked and becoming, like, familiar. 2

4 5

I felt much more confident, at the end of the four months, that I could assess, you know, intensive care patients and make basic decisions. Nothing fancy but at least hold the fort for like an hour or so.

6

Having the opportunity to do intensive care and anaesthetics as my first FY2 job which… because I was interested in it and I was given that by the programme director; he organised that, so I had 8 experience in that before I applied, which I was very grateful for. Having done that I knew that was 9 what I wanted to do and so I applied. 7

10

So I was very much still thinking do I want to go down the emergency medicine route, do I want to go down, you know… I want to do intensive care. Anaesthetics is interesting but I didn’t think I want to do 12 it. Didn’t get an A and E job but I got an intensive care job and then, I think, as I met the people with 13 the emergency medicine doctors; I learned a bit more about how I liked to work…I think people talk 14 about personalities and I thought maybe my personality wasn’t actually quite aligned to emergency 15 medicine but I really enjoyed anaesthetics.

Fo

11

rp

16

I got to work with the anaesthetist and thought actually I could fit in here and that’s an opportunity I might not have had and if, say, anaesthetics… No say ICU would be my last job, I might not have been 18 so confident. Even if I’d done it as FY2 but we’re starting it in April instead of August. I might not have 19 been confident; I might have taken it…

ee

17

20 21

rr

SP1 So that almost shaped your decision then if you say that happening even shaped your decision to have the confidence to do that?

ev

22

SP2: Yeah, yeah, I might have waited another year to do that instead of I’ll see how I find it at the end of the year. I’ll take the year out locum and then apply once I know what I want to do. It’s difficult to 24 know what I would if things had been different. 23

25

iew

I remember talking to friends and I’d always… As I said, I thought I wanted to do an acute specialty, maybe emergency medicine, maybe intensive care, and I’d enjoyed anaesthetics. I was so well 27 supported by all the different consultants and I enjoyed the hands on… You know, it felt right and 28 having the opportunity to do that I knew that this is what I want to do. I’ve been asked, as I’m sure 29 every junior doctor or medical student is asked for a few years, what kind of doctor do you want to be?

26

30

on

I never had an answer and it was really August, and it came quite suddenly, it was kind of like it’s a lightbulb moment because just thinking a year ago I was still between two or three specialties. As 32 soon as I did that I was like, yeah, I’ll do this. This is great; I can be an anaesthetist… This is what I 33 enjoy which some people go to medical school knowing they want to be a specific type of surgeon or a 34 GP. It took me until I was actually doing that job as a FY2 to say this is for me. 31

35 36 37

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

SP1: So would it be fair to say almost that positive experience of getting an opportunity to practice… almost helped along that pathway as well with prior to making a decision. SP2: Definitely. As I said I might not have applied to (ACCS) training…

38

SP2: Yes, for the next… Well, if I get to retire. That… It’s a decision that I don’t think I would’ve made. Actually thinking back to making that decision, knowing how confident I was that I enjoyed 40 anaesthetics; it still felt like a big thing to click that button and apply for that job. I most definitely 41 wouldn’t have done that if I hadn’t had that experience in anaesthetics. 39


BMJ Open

Box 3- Abigail’s Story 1 2 3 4 5 6

Yeah, so as a whole, I found the foundation experience really disappointing. I’ve not enjoyed it all as a profession, or as a job. I felt that you’re extremely undervalued as an individual, and as a professional. And there’s huge neglect of training for foundation doctors, especially at FY1 level. I don’t think that you’re respected or considered to be a practising clinician. I think there’s not much in the way of recognition for the work that you do. And I think that you do a lot of legwork for a lot of other people. And people aren’t very thankful of that.

7

I don’t think that you’re treated well by other members of healthcare professionals within the teams. And that makes your role feel devalued as well. You feel devalued in that sense that other people 9 don’t treat you very nicely at all.

8

10

Fo

As a whole…as a whole it’s really, I found it very disheartening. And I had never expected to be treated 11so badly as a professional. 12

rp

Bearing in mind that this is your first ever experience of a job. And often, medical students or medics don’t necessarily work much before they go to university. This is the first time you ever experience 14 working life. And those that work within the institution should know better that it’s a very, very difficult 15 job. 13

16

ee

And that on the whole, they’re treated very badly. But I don’t think that makes any difference. And I don’t think it means that people make any effort at all to be inviting, to be encouraging, to be 18 supportive of the fact that you are a young professional that has no experience working in a 19 professional environment. And I think that was one of the biggest things that I found so difficult. 17

ev

20

rr

I don’t think if you went to any other institution, any other organization, anywhere as a professional, or in any other business they would make you feel crap in the first… You know, having that first 22 experience, you know, I mean, you know what I mean to work somewhere in the first year. 21

23

iew

You just feel totally disengaged, and very down trodden. And you feel undervalued.

24

I found it really disappointing. Like, I’ve spent years training to do this job. And I really, really wanted to do it. I’ve always wanted to be a doctor. And I got here, and I’ve just found it devastating. I’ve 26 really been so disheartened, and just put off with the profession as a whole just because the way in 27 which the work is’. 25

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 40 of 44


Page 41 of 44

Box 4- Gemma’s Story 1

And then other times, when you have, you don’t have the senior support that you need, for whatever reason; they’re caught up doing something else, or… And then you’re, you feel out of your depth. 3 Especially when you’re SHO, and the reg is the next tier and if they’re in theatre or they’re with another 4 sick patient, then you, kind of, feel a bit like you’re out of your depth sometimes. Which is sometimes fun 5 if you manage to sort it out, but sometimes a bit overwhelming and exhausting.

2

6

I can find things quite upsetting that I probably would normally be able to deal with quite well. Things about, you know, outside of work would affect me more, or… Yes, just feel a bit… Sometimes if you’ve 8 not… You’ve literally been at work, slept, and been at work for seven days; you’ve had no social 9 interaction at all outside of work, and that also gets you down. Because, you know, you need to do, you 10 see friends and do fun things that will let you relax, to be able to maintain a, kind of, healthy 11 emotional state. 7

12

Fo

I did have a case, when I was in paediatrics, where I didn’t feel supported at all by my seniors. In fact, the opposite, by the consultants, and it really upset me and got me down and affected me for months, 14 so… And at the end of that, I thought, no, I don’t want to. I decided to take a year out from that. 13

15

rp

There was a patient that became seriously unwell, that I didn’t know that the baby was unwell, and then got, kind of, blamed for it afterwards, despite the fact that I tried to escalate it and they didn’t really, 17 like, want to take any kind of responsibility. And I tried to get some help and no one would come to 18 help. And then I, kind of, got blamed for it and not supported through it, not debriefed or… I just, kind 19 of, felt like it was my fault and then I had to kind of process it and deal with it on my own, rather than 20 having… 16

21

rr

ee

We have our clinical and educational supervisors that are meant to help us through those, like, the emotional aspects of our work, as well as all the practical aspects of just getting through the course. But 23 Box Story it,5-itClare’s all, they’re all consultants that take on that role, so… And obviously, every personality differs, and 24 everyone… So I was just unlucky that all of the consultants there didn’t really seem to care about that. 25 And there wasn’t anyone that I felt like I could ask. 22

iew

ev

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Box 5- Clare’s Story 1

Erm I think now, the longer I work for, not having any control over my annual leave, my days off, my time off, is really starting to really annoy me. So my next rota, for example, I have just been informed, 3 you have three weeks’ annual leave, this is when they are, you can’t swap them, you can’t move them, 4 tough. I think that that is a disgrace. 2

5

The number of hours I have worked to be told, you’re not allowed to go on a family holiday that you’ve booked. You’re not allowed… I’ve been told I’m not allowed to go to a funeral before. I’ve been 7 told I’m not allowed time off when I’m ill. That… I would have said, is the worst thing. I just, I don’t think 8 it’s fair, and I think that bothers me more and more, I think, as time goes on. 6

9

I think, particularly my, like, having been in {Psychiatric hospital} now for 12 weeks, the thought of coming back to X hospital…it’s horrifying. I just am dreading it. I’m absolutely dreading having to 11 come back. And when I saw the rota… Whichever idiot person made the rota, who has never worked 12 as a doctor and has no idea what they’re doing… I was almost in tears, looking, and just thinking, oh 13 God, half nine. So, a quarter of all of my shifts, I finish at half past nine at night, which means I don’t 14 get home until after ten, which means I won’t see my partner for the next four months. That, I just… 15 That’s the worst bit, I think.

10

16

rp

Fo

I would have said, there were certain bits that have made me think, I’m 100% positive I don’t want to continue working in this hospital. And I would have said… My second job in the FY1 was {a surgical 18 specialty}…There was meant to be two FY1s and two FY2s. The FY2s were on the registrar rota, which 19 was hell on earth for them, and therefore I was the only FY1, and there were no FY2s because they 20 were on the reg rota. 17

21

rr

ee

And I was put in horrific, horrific situations...there was one horrendous weekend where I had three people in the HDU, had sixty patients, and then I had another four beds due where I had four people 23 that were really sick with pneumonia. And I hadn’t had a medical job, and I didn’t know what I was 24 doing, and I have never in my life felt so overwhelmed, and I just… I hated it, I absolutely hated it. I 25 didn’t get support; I’d phone the registrar to come in, they came in in the morning for an hour, did a 26 ward round and just left. And I was left on my own for a full weekend. 22

27

iew

ev

I’ve got GP training; I’ve accepted a GP position… The thought of actually having to spend any more time in that hospital is just horrifying, but I think…So the thought of having to do six, seven years to 29 consultant, there’s no way. There’s literally no way I would do it.

28

30

on

Management don’t know who I am, don’t know what I’m about. And if I raise a concern, I think they see that you’re a hassle, it’s a problem, as opposed to, you’re a valued team member that they think 32 is worth being there. I don’t, yes, I don’t feel valued in that capacity. 31

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 42 of 44


Page 43 of 44

Figure Legends: Title: The Theory of Perceived Organizational Support Figure one: Perceived Organizational Support and its components. Title: Personal Stories Shared by F2 Doctors. Box 1: Daniel’s Story Box 2: Steven’s Story Box 3: Abigail’s Story Box 4: Gemma’s Story Box 5: Clare’s Story

iew

ev

rr

ee

rp

Fo ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

iew

ev

rr

ee

rp

Fo 198x148mm (300 x 300 DPI)

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 44 of 44

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

Does Perceived Organizational Support Influence Career Intentions? The Stories Shared by UK Early Career Doctors.

Journal: Manuscript ID

BMJ Open bmjopen-2018-022833.R1

Fo

Article Type:

Date Submitted by the Author:

Research 15-May-2018

rp

Complete List of Authors:

Secondary Subject Heading:

Qualitative research

iew

Keywords:

Medical education and training

ev

Primary Subject Heading:

rr

ee

Scanlan, Gillian; University of Aberdeen Institute of Applied Health Sciences, Centre for Healthcare Education Research and Innovation (CHERI), Institute of Education for Medical and Dental Sciences, School of Medicine, Dentistry and Nutrition Cleland, Jennifer; University of Aberdeen Walker, Kim; NHS Education for Scotland., NHS Education for Scotland and UK Foundation Programme Johnston, Peter; NHS Education for Scotland, North Deanery

MEDICAL EDUCATION & TRAINING, QUALITATIVE RESEARCH, EDUCATION & TRAINING (see Medical Education & Training), OCCUPATIONAL & INDUSTRIAL MEDICINE

ly

on For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 1 of 46

Does Perceived Organizational Support Influence Career Intentions? The Stories Shared by UK Early Career Doctors Gillian Scanlan1, Jennifer Cleland1, Kim Walker2 and Peter Johnston2

1

Centre for Healthcare Education Research and Innovation (CHERI), Institute of Education for

Medical and Dental Sciences, School of Medicine, Dentistry and Nutrition, University of Aberdeen, Aberdeen, Foresterhill, AB25 2ZD 2

Fo

NHS Education for Scotland, Scotland Deanery (North), Foresterhill.

rp

Correspondence to: Ms Gillian Scanlan

ee

Email: [email protected]

iew

ev

rr ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Abstract Introduction: The wish to quit or take time out of medical training appears to be related, at least in part, to a strong desire for supportive working and learning environments. However, we do not have a good understanding of what a supportive culture means to early career doctors, and how perceptions of support may influence career decision making. Our aim was to explore this in UK Foundation doctors. Methods: This was a qualitative study using semi-structured interviews incorporating a narrative

Fo

inquiry approach for data collection. Interview questions were informed by the literature as well as

rp

data from two focus groups. Interviews were carried out in two UK locations. Initial data coding and analysis were inductive, using thematic analysis. We then used the lens of Perceived Organizational

ee

Support (POS) to group themes and aid conceptual generalizability.

rr

Results: Twenty-one interviews were carried out. Eleven interviewees had applied for specialty training, while ten had not. Support from senior staff and colleagues influenced participants’ job

ev

satisfaction and engagement. Positive relationships with senior staff and colleagues seemed to act as

iew

a buffer, helping participants cope with challenging situations. Feeling valued (acknowledgement of efforts, and respect) was important. Conversely, perceiving a poor level of support from the organization and its representatives (supervisors, colleagues) had a detrimental impact on participants’ intentions to stay working within the NHS.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 2 of 46

Conclusion: Overall, this is the first study to explore directly how experiences in early postgraduate training have a critical impact on the career intentions of trainee/resident doctors. We found perceived support in the early stages of postgraduate training was critical to whether doctors applied for higher training and/or intended to stay working in the NHS. These findings have transferable messages to other contexts struggling to recruit and retain junior doctors.


Page 3 of 46

Strengths and Limitations of this Study •

This study used a narrative inquiry approach to capture meaningful and purposeful stories that would resonate with readers and thus not lose critical elements of the experiences of early career doctors.

•

Interviews were carried out with F2 doctors during their foundation programme, therefore the experiences and stories shared were in direct observation to their working and learning environment, and thus were not in danger of recall bias.

•

Fo

It builds on the existing literature that directly relates to factors that influence career decision making of early career doctors and addresses the limitations of previous work by

rp

using the social theory of Perceived Organizational Support as a theoretical conceptual

ee

framework to provide deeper insight and the use of semi-structured interviews to gain thorough understanding of this phenomenon. •

rr

It is limited as we only interviewed F2 doctors from Scotland, and perhaps the views of those

ev

in Scotland may not be representative of those from the rest of the UK.

iew

Introduction

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Early medical careers decision making is a complex process which involves balancing job-related factors such as location of the post, working conditions, and personal factors such as “fit” with a specialty or close proximity to family and friends1-4. There is increasing evidence that prior workplace experiences are important in careers decision-making5, most obviously in terms of a clear relationship between exposure to a specialty and later preference for that speciality6-8. Contemporary evidence suggests that early career doctors also draw on prior experience of the


BMJ Open

supportive culture, or not, of a unit/department/locality, to inform their careers decisions2,9. For example, evidence from countries including Germany, Netherlands, Australia, Finland, Canada, and the United States indicates that residents/trainees who experience a positive working culture (characterised by, for example, high quality training, and work-related social support) are less likely to have intentions to quit medical training or to wish to move into medical jobs without patient contact1,10,11. In our own context, the UK, there is a recent pattern of a large proportion of early career doctors not applying for specialty training at the time when they become eligible to do so.

Fo

Instead, approximately 50% of doctors at this stage are taking time out of the training system. The majority of those who take time out of training continue to work in the NHS but in service posts

rp

(posts that are not part of a training programme towards a particular specialty). Why this trend has

ee

become more obvious in recent years is of considerable interest to NHS employers, institutions responsible for medical education and training as well as researchers.

rr

Recent studies suggest that the wish to quit or at take time out of medical training may be related,

ev

at least in part, to a strong desire for supportive working and learning environments4,12,13. UK

iew

Foundation Year 2 (FP2) doctors ( these doctors form part of a generic two-year vocational training programme that bridges the gap between medical school and specialty/core training) who experience pressurised working environments with poor autonomy over their personal and work life

on

report reductions in morale and motivation, and feelings of dehumanisation. However, the nature of

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 4 of 46

this previous research - predominantly survey-based10,11,14,15 or descriptive qualitative inquiry12– means we do not have a good understanding of what a supportive culture means to early career doctors. Nor do we know how their perceptions of support or sources of dissatisfaction may impact on their career decision making. It is critical to explore these issues in detail as identifying ways to increase satisfaction with medical training may help stem issues with uneven distribution of doctors in terms of specialty and


Page 5 of 46

location16-19 and help attract sufficient doctors to apply for training posts, and hence meet anticipated immediate and future healthcare needs20,21. Our aim in this study was to explore FP2 doctors’ work-related experiences in relation to work-place support, and how this may have influenced their careers intentions. To extend understanding of this phenomenon and bearing in mind that using orienting concepts derived from social theory can enhance knowledge, understanding and interpretations that might not be identified using inductive approaches22, we used the theory of Perceived Organizational Support (POS)23,24 as a theoretical

Fo

framework to aid conceptual generalizability and to highlight possible ways forward for medical

rp

education and employment policy and practice.

iew

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Methods Conceptual Framework Perceived organizational support (POS) is the relationship resulting from the reciprocal exchanges25 between an employee and the organisation23. POS relates to an individual’s perception of whether the organization values their work contributions and cares about their well-being23,24. Where employees perceive that the organization values and supports them, they will develop greater emotional attachment, engagement 26,27 and feelings of obligation to the organization28,29. This, in

Fo

turn, is positively related to a range of employee behaviours30,31 including intention to stay with the

rp

organization32-34, job satisfaction31,35, dedication34,36 and commitment to the organisations goals15,29,36. Commitment

rr

ee

POS suggests that reciprocity between employee and organisation can be expressed and evaluated

ev

as three, inter-related types of commitment: affective, normative and continuance (see Figure 1).

iew

Affective commitment refers to an individual’s emotional attachment to the organisation and is linked to the individual and the organisation’s goals, values and norms being similar, or in alignment33. If an individual has a high level of affective commitment to the organisation then they

on

are more likely to be satisfied with their job and may be more likely to stay with that organisation31,34,36,37.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 6 of 46

Normative commitment is the level of obligation and sense of loyalty an employee feels towards the organisation. This is related to individuals feeling acknowledged and rewarded by (via, for example, promotions, incentives)28,38, and hence indebted to, the organisation which again may be demonstrated by wishing staying in the employment of that organisation. In other words, if an individual feels their organisation has shown commitment to them, they are more likely to show commitment to the organisation– and vice-versa33,34.


Page 7 of 46

The third and final level of commitment is continuance commitment. This is associated with employees evaluating the advantages and disadvantages of continuing to work for the organisation versus leaving the organisation14,31. Are they guaranteed better opportunities somewhere else, or are there too many risks associated with leaving? The three levels of commitment are not separate entities. Rather they overlap and link with one another. For example, if an individual develops an emotional attachment and dedication to the organisation (affective commitment), and the organisation has recognised and rewarded their

Fo

efforts, they may have a sense of loyalty to the organisation (normative commitment), and not wish

rp

to leave (continuance commitment) (see figure one). The role of others

ee

An important concept in POS is that any actions undertaken by other people within the organisation

rr

are perceived by the employees as acts of the organisation rather than the individual32,39 (see figure

ev

one). Perceived supervisory support (PSS)40: is an indicator of how much the organisation values the individual, and the personification of the organisation in this way leads to employees interpreting

iew

the actions of those more senior to themselves as reflecting the norms or the values of the organisation. Where individuals do not feel fairly treated or supported by senior staff, their sense of

on

attachment and obligation to the organisation decreases, and their inclination to leave (turnover intention) increases29. On the other hand, high levels of PSS - enacted via, for example, autonomy,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

participation in decision making, professional development opportunities, rewards and praise1,10,34 – may support an employee’s job satisfaction, emotional attachment, obligation and intent to stay with an organization34,37,41,42. Employees also evaluate the behaviour of team members and colleagues as personifying organisational norms and values, with the same outcomes in terms of organisational commitment as observed with senior staff28. Positive relationships with colleagues and team members are also important in another respect. These interpersonal relationships offer information about how to 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

become a successful organization member, as well as provide friendships that make work-life more pleasant15,33,43. Having role models, support and praise from more established colleagues positively affects the organisational commitment of newcomers into an organisation 41,9,44. POS has been used to explain performance, work-related stress, intentions to leave, organisational commitment and job satisfaction across a range of commercial and healthcare settings15,28,33,41,,44. On scrutinising the themes in the data, we were struck that many of these seemed to relate to the relationships our participants had with the organisation in which they worked, and the people they

Fo

worked with. It was this that led us to use the theory of Perceived Organisational Support 24,26,27 to

rp

help understand and explain the data identify important factors and their potential relationships.

iew

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 8 of 46


Page 9 of 46

*****Figure one about here*****

ee

rp

Fo Design

rr

In line with our worldview meaning is constructed through social interaction, this research is

ev

epistemologically grounded in social constructionism45,46. We used individual interviews to collect multiple perspectives and interpretations of reality in relation to the research question. Sampling and recruitment

iew

Our target group was Foundation Programme (FP) doctors in the UK. After graduating from medical

on

school, UK doctors work in the FP for two years full-time or the equivalent part-time. The FP is

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

designed to ensure broad based training across the breadth of specialties with compulsory surgery, medicine and a “community” placement (e.g., general (family) practice, mental health). It aims to develop the clinical and professional skills of medical graduates, so they are prepared to progress into one of the range of speciality training pathways at the end of year two of the FP. The first opportunity for application for a specialty training post is in mid FP2, and traditionally most doctors applied at this stage of their career. However, things have changed in the last five years or so: only about half of FP2 doctors now apply for Speciality or Core Medical Training19. Core medical training (CMT) is a two-year course following the FP. CMT rotations typically last between 4-6 months and 9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

trainees rotate across various medical specialities. Trainees must successfully complete CMT and undertake the full Membership of the Royal College of Physicians (MRCP)(UK) Diploma in order to apply for speciality training at ST3. However, some training programmes allow trainees to go straight into speciality or general practice training after completion of the FP. These are typically referred to as run-through programmes. The length of training and structure varies between specialities, training can last between 3-8 years depending on the speciality. The others typically either take up a service post as mentioned earlier,

Fo

work overseas for a period of time, or leave the profession. The organisation of UK medical training

rp

means that this change in careers-related behaviour leaves many unfilled posts, insufficient doctors to meet immediate healthcare needs and a potential shortfall of specialty-trained doctors in the longer term20,21.

rr

ee

Upon receiving ethical approval and appropriate institutional consents (see later), FP2 doctors from

ev

two of the five Scottish FP regions were invited to participate in individual interviews. These regions are diverse in terms of size and geographical locality, and because local data indicates that they

iew

attract different groups of FP doctors in terms of home origin and medical school attended. FP coordinators from the two regions sent out an email giving details of the study and the

on

researcher’s contact details to the 2015-2016 cohort of FP2 doctors. Those who were interested in taking part in the study were asked to contact the main researcher directly, by email. Those who did

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 10 of 46

so were provided with more information about the study and invited to take part. Patient or Public Involvement No patients or any members of the public were involved in this study. Data collection

This study used semi-structured interviews incorporating a narrative inquiry approach for data collection47. The interview schedules explored FP2 doctor’s experiences of their postgraduate 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 11 of 46

training and how this influenced their career intentions. The interview questions were developed by drawing on the broad literature on medical careers decision making, particularly contemporary papers from the UK context2-4,9. We also drew on discussions on this topic arising in formal teaching sessions with FP doctors in the 12 months prior to data collection. The questions were piloted with a small group of volunteer FP doctors who did not take part in the main study. Our approach was iterative: we used our notes and recordings from early interviews to inform the development of additional questions for later interviews. The interview schedule is available on request.

Fo

In order to elicit as broad a range of understandings as possible, maximum variation sampling was

rp

used to ensure diversity in terms of gender, graduate entry or school-leaving status as a medical student, ethnicity, location, and whether or not the individual had applied for a training post in FP2

ee

or not. Individual interviews were carried out at times and places convenient for participants.

rr

Participants were provided with refreshments but no other incentives for taking part. At the end of each interview, participants were thanked for taking part. Data Analysis

iew

ev

All interviews were audio recorded with participant permission, transcribed for analysis, and entered on to NVIVO PRO 11 qualitative data management software. Familiarisation and data checking were

on

achieved by listening to audio-recordings while reading transcripts. Thoughts and insights were recorded as a memo file for each doctor. Initial data coding and analysis was inductive, using

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

thematic analysis to generate a coding scheme48. Analysis progressed via regular team meetings, where ongoing coding and comparisons were explored. Comparisons were made between codes and participants to explore differences and similarities in participants’ perspectives. Any discrepancies were discussed and then agreed upon. Analytical ideas and discussions were documented through memos and team correspondence that created an audit trail of the analytic process. As discussed earlier, after inductive coding we utilised POS as an analytic framework.


BMJ Open

Rigour was ensured in several ways49. All interviews were undertaken by the first author (GS) to ensure continuity. We considered our positions and relationships with the data continually and critically50,51 in view of our different disciplinary backgrounds (psychology; medicine), different levels of knowledge and experience of delivering and managing medical education and training, and research perspectives and preferences. We constantly reflected on how these might have shaped our co-construction of the data. Preliminary data analysis was shared and discussed with colleagues outside the research team to explore if the findings seemed credible and reasonable52. The main

Fo

researcher was a PhD candidate; thus this study was part of a larger doctoral research project that aimed to explore the working and learning environments of F2 doctors and their career intentions. Ethical approvals

ee

rp

This study was granted ethical approval from the host university’s Ethics Research Board. This was

rr

accepted as evidence of ethical approval by the second site’s equivalent board. Approval and

ev

permission to carry out the study were also obtained formally from the relevant NHS (National Health Services) Research and Development (R&D) departments. Written consent was obtained from all participants.

iew ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 12 of 46


Page 13 of 46

Results Twenty-three FP2 doctors expressed an interest in study participation. Two were not available for interview during the period of the study (January to April 2016). Of the 21 who participated: eight were from Region A and 13 from (the larger) Region B; 13 were female, eight male; 17 had entered medical school directly from high school (the norm in the UK) while four were graduate entrants; 13 were born and raised in Scotland, six were born and raised elsewhere in the UK and two were from mainland Europe. Most were of White British ethnicity. Their ages ranged from 25-35 years old. Of

Fo

those interviewed, 11 had applied for specialty or core training in FP2. They had applied to a range

rp

of hospital and community specialties, including Anaesthetics, General Practice, Psychiatry and Core Medical Training.

ee

The median interview length of interviews was 30.26 minutes (from 18 minutes to 52 minutes).

rr

Our initial framework analysis identified the main themes captured in the data from across the

ev

participant group. These were: positive supervisory support, poor supervisory support, team environment, and feeling valued. We then used the POS theory to interpret and organise the data.

iew

This worked effectively yet we felt that presenting the data thematically failed to illustrate the critical experiences of our participants53,54. Instead, and with reference to Kendall and Kendall’s

on

(2012)55 view that ‘the whole story is greater than the sum of its parts’ (p.179), we present the data as the stories told by participants to the researcher56. This allowed us to explore the multiple

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

dynamics of workforce relationships and experiences, and related decision making57. We chose five stories that exemplified the main themes well, where participants lay out how they experienced certain events and conferred their subjective meaning onto these experiences. We provide personal background characteristics for each story told58, to give the reader a deeper knowledge and understanding of each person’s story55. We present participant’s key stories in their own words59.


BMJ Open

Story 1: ‘I think senior support at time was a huge factor for us…’ In this first story (see box 1), Daniel (please note all names are pseudonyms) is a male foundation doctor. He is originally from Northern Ireland but came to Scotland for medical school and stayed on

Fo

to do the FP. Some members of Daniel’s family had worked in the healthcare sector although not

rp

directly in medicine. He worked in various part-time and volunteer jobs during his medical degree. Daniel lives with his long-term girlfriend who is also a foundation doctor. Daniel had a particularly

ee

positive experience throughout his time on the foundation programme, the most noteworthy experience for him was his experience in his A&E rotation. In Box one we see clear examples of how

rr

feeling supported and feeling valued played a key role in influencing Daniel’s decision to apply for speciality training.

iew

ev …………… Box 1 about here…………..

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 14 of 46

In this story we can identify that Daniel’s experience of a positive working culture impacts both his commitment to the organization and the perception of support that would be available in the future. This is evidenced when Daniel explains that he has applied for Anaesthetics training and indicates one reason for applying is related to the level of support that he will gain in this particular specialty (lines 18-22). We can infer from Daniel’s story that, for him, a supportive working environment is based on a culture that is enriched with ‘enthusiastic’ supervisors who are willing to ‘take an interest’ in the professional careers of FP2 doctors and that helps to really ‘make it’ an enjoyable experience (lines 9-13). Daniel’s story has emotional elements to, in that he describes ‘feeling 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 15 of 46

valued’, and this influences his commitment to the organisation and motivates him to apply for anaesthetics (lines 9-10). In terms of POS theory, Daniel may attribute the acts undertaken by his supervisor as evidence of the level of investment and value the organization places on his personal and professional development15,32. The level of investment that the senior member of staff demonstrated in Daniel’s A&E rotation helped to convey the future behaviours that would be present in the NHS which enabled him to recognise attributes of supervisors which would enhance his own future working

Fo

conditions and made him feel more invested in a specialty that offers a high level of ‘one-on-one’

rp

training with seniors. Overall, this story illustrated the key influence a positive clinical supervisoremployee relationship can have on an early career doctor’s intentions to stay working in the NHS.

rr

ee Story 2- ‘Having done that, I knew that was what I wanted to do and so I applied…’

ev

In this second story, Steven is a male foundation doctor. He is originally from England and did his

iew

medical degree there as a graduate entrant. He moved to Scotland for the FP. He worked part-time throughout both his degrees. He comes from a non-medical family and a working-class background. Steven had a girlfriend from Scotland who was pursuing a non-medical degree within Scotland.

on

Steven explains a critical point in his F2 programme which helped him develop sufficient confidence to apply for speciality training (Box 2).

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

**********Box 2 about here*********

Steven’s story highlights the importance of having seniors who want their junior members of staff to flourish in their working environment. He remarks he could have ‘easily been given rubbish tasks to


BMJ Open

do’ but instead received good training opportunities (lines 1-2). From the very beginning of his FP2 Steven feels like a valued member of the team and that seniors are eager for him to learn on the job. The timing of his anaesthetics rotation was critical. Steven reflects that without the direct experience of working in anaesthetics and being able to compare it with his other FY experiences, he would have not known that this specialty would “fit” him in terms of his personality and what he enjoyed in the workplace (lines 6-9, lines 16-19). Having the support from ‘different consultants’ played a critical role in Steven applying for acute

Fo

care common stem training programme (three-year programme which covers acute specialities

rp

including anaesthesia, emergency medicine, acute medicine and intensive care) (lines 20-22, lines 26-28). The level of commitment that was shown by the seniors was perhaps a direct indicator to

ee

Steven that his professional development and well-being would be looked after if he trained in

rr

anaesthetics within the NHS (lines 40-41).

ev

Viewed through the POS lens, it seems that Steven’s level of obligation to the organisation28,29. It seems that Steven’s level of obligation was influenced by both feeling valued34 and perceiving that

iew

senior members of staff had invested a great amount of time and energy to ensure that he gained important opportunities prior to applying for speciality training15. These positive encounters seemed

on

to influence his intentions to not take a year out of training but to apply for specialty training in FY2.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 16 of 46

Story 3: ‘I really, really wanted to do it. I’ve always wanted to be a doctor. And I got here, and I’ve just found it devastating’ In this third story, Abigail is a female FP2 doctor. She is originally from England, and did her medical degree there before moving to Scotland for the FP. The FP was her first experience of working life. She comes from an affluent, medical family background. She is single and living alone. The FP was not a positive experience for her and she did not apply for specialty training (Box 3).


Page 17 of 46


Abigail reflects that she found the FP disappointing on a personal and professional level, which ultimately affected her morale and commitment to the NHS (lines 1-2). Abigail goes on to highlight how she was ‘very’ disheartened by the NHS and never expected to be ‘treated so badly as a

Fo

professional’. She expressed feeling mistreated and not feeling welcomed by team members (lines 5-11, lines 17-18). This perceived lack of support during her FP ultimately deterred Abigail from the

rp

‘profession as a whole’ (lines 24-25).

ee

When evaluating Abigail’s story, we can extrapolate that she feels like the NHS does not value or care about the well-being of their junior doctors. This would fit with one important concept of POS:

rr

that employees assign human like characteristics to the organisation they work for24,26,27. For Abigail,

ev

the poor treatment she receives from members of her immediate team exemplifies to her the way

iew

the whole NHS works. Thus, supervisors and established team members not treating juniors fairly can lead to low affective commitment, ultimately leading to higher turnover intentions (and conversely the research has shown this evidence: Otto & Mamatoglu, 201537; Rhoades et al., 200127; Malik et al., 201614).

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Story 4- ‘And at the end of that, I thought, no, I don’t want to. I decided to take a year out from that’. This fourth story was from Gemma, a 25-year-old Female Foundation Doctor, originally from Wales, where she completed medical school. She moved to Scotland for the FP. She is single, and all her family and friends still live in Wales. She comes from a non-medical family but has family members who were healthcare professionals. Gemma had experience of doing some charity and voluntary 17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

work throughout her degree. Box 4, explains a critical experience Gemma had in her paediatrics rotation and how this incident had a detrimental impact on her intention to apply for training and instead opt to take a break.


Fo

Gemma reflects that she found it ‘a bit overwhelming and exhausting’ when senior staff were not

rp

available to help or support her. She describes a critical incident that involves a death of an infant baby and how she is blamed for this afterwards (lines 12- 16). The most difficult factor for Gemma is

ee

that she is not ‘debriefed or supported through this’ and leaves her feeling responsible for a child’s death (lines 17-19). This specific incident not only affected Gemma at personal level but also at a

rr

professional level as it was at end of that rotation that she ‘decided to take a year out from that’.

ev

From a POS perspective, Gemma did not experience a sense of emotional (affective) commitment

iew

from her senior members of staff at a critical time. She did not feel like the NHS cared and respected her at a professional or personal level. We can infer from Gemma’s story that positive relationships with senior staff not only increase the perception of support, but they also seem to act as a buffer

on

which helps more junior doctors to cope with challenging situations15,37,41,60. Where this is lacking,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 18 of 46

emotional obligation to the organisation is affected, which can impact on turnover intentions (as per Gemma deciding not to apply for specialty training28,29,34.

Story 5: ‘Management don’t know who I am… I think they see that you’re a hassle… as opposed to, you’re a valued team member…’ The final story is told by Clare. She is from Scotland where she completed her medical degree as a graduate, before doing her FP in Scotland. She worked before and during medical school. She comes 18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 19 of 46

from a non-medical family and her fiancée is non-medical. She plans to start a family within the next few years. Clare shares many challenges she experienced throughout her foundation programme in both her professional and personal life. In Box 5, she highlights a particular incident that occurred that put her off working in hospital medicine.


Fo

Clare reflects that her personal life is not something that is valued by the healthcare team and not being able to control her working hours is a source of frustration (lines 5-8). There is a sense that her

rp

annual leave is not something that is respected or valued by the management and that when Clare

ee

queries this she is deemed ‘a problem’ (lines 2-4, lines 30-32). Clare describes a critical experience in her neurosurgery rotation in which she felt under supported

rr

and highlights she was ‘put into horrific, horrific situations’ (lines 21-24). This negative experience

ev

had a lasting impact and was influential in terms of putting Clare off working in the hospital in which

iew

she completed her F2 training: there is ‘literally no way’ she would work in that hospital again (lines 27-29).

From a POS perspective feeling valued by the organisation is a strong motivator for participants to

on

stay invested in that organisation, and vice-versa (as was the case for Clare). Lack of appreciation of

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

her personal needs (annual leave requests) led to her disengagement and reduced commitment towards working in that hospital ever again (continuance commitment: Eisenberger & Stinglhamber, 201141; Rhoades & Eisenberger, 200227; Allen et al., 200333; Kaplan et al., 201235). Instead, Clare opts to apply for GP training, perhaps perceiving that this will provide better working conditions which will illustrate that she is valued and an important member of the team.

Common themes 19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

We also looked to identify any overlapping patterns across data which were exemplified in the five stories61. Daniel and Steven were afforded opportunities to engage with several senior staff on a regular basis, their working environments were supportive, and they gained exposure to specialities prior to applying for specialty training. On the other hand, Gemma and Abigail had very negative experiences of the foundation programme and developed a negative personification of the organization as a whole with a particular focus on a lack of support from team members. A lack of support during time critical situations was enough to put Clare off working in a specific hospital

Fo

again and enough to put Gemma off applying for training at completion of FP2. The data suggests that support, encouragement and feeling valued underpin organisational commitment and turnover

rp

intention in FP doctors.

iew

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 20 of 46


Page 21 of 46

Discussion To the best of our knowledge, this is the first study to explore what a supportive culture means to early career doctors, and how perceptions of support may influence career decision making. The data indicated that support from supervisors/senior colleagues and team members influenced organisational engagement. Having positive relationships with other staff increased the perception of a supportive culture but also seemed to act as a safeguard when challenging situations arose. The opposite was also true. Those who perceived poor senior and/or team support tended to have a

Fo

negative personification of the organisation and had higher intentions to leave the NHS or opt to

rp

work in a different speciality. In short, the behaviour of people within the organisation was an indicator of whether or not the NHS cared and respected the individual as a member of the organisation.

rr

ee

Our findings align with the wider organisational literature. For example, having a high level of

ev

support from supervisors or more senior colleagues (Perceived Supervisory Support: PSS: see earlier) can lead to increased loyalty in the workplace62, better job performance63 and increases in

iew

psychological well-being64, as well as having a positive impact on employee retention40,65,43. Indeed, PSS is becoming one of the most influential factors in predicting turnover intention: the less support

on

from a supervisor, the more likely the employees are to leave the organisation (or specialty), and vice-versa32. However, the POS theory may have limitations in contexts such as the UK, where there

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

is only one healthcare training provider, the National Health Service (NHS). In such “monopoly” situations, there may be a less obvious relationship between continuance commitment and turnover intentions14. On the other hand, doctors in training can still “vote with their feet” by applying to train in a different speciality or region, take a break from training, or move overseas to seek better opportunities. This represents early career doctors are taking responsible for their own career development. That they are doing so in a different way from what is expected by the training system


BMJ Open

structure, which is perfectly reasonable from an individual perspective- but is an issue for the system where trainees are integral to service delivery. While perceptions of support varied, our data also suggested that there were differences in how participants engaged with their working environments. Different FP2 doctors interpreted what seemed to us as reasonably similar situations in different ways: as either an opportunity (to work independently) or, conversely, as a situation where they felt unsupported. This fits with theories which conceptualise learning through work as a relational interdependence of affordances

Fo

(opportunities) and the readiness of the individual to engage with these opportunities (i.e. how

rp

individuals respond to what is offered in the workplace)66. For example, one relevant factor seemed to be prior work experience. For some participants this was their first work experience. Others had

ee

held many part-time jobs while at university. The data hinted at this personal factor shaping

rr

participants’ interpretations of experiences. Other external factors may also play a role in shaping foundation doctors’ career decisions, for example the need to work to pay off student debt. This

ev

requires further independent investigation and in terms of how seniors can supportively manage trainees’ expectations to mitigate stressors.

iew on

We started our study without preconceptions of what we might find. The choice of theory was decided by the data when we realised that social relationships and organizational culture were key

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 22 of 46

elements in our participants’ stories. Interestingly, the main theoretical frameworks used in studies of work-based medical training are socio-cultural views on learning67,68. Our data directed us to organizational theory, thus providing a fresh perspective on a well-acknowledged issue and responded to calls in the literature to focus on the organisational context of postgraduate training6870

. The use of a theoretical lens also allowed us to progress from knowledge gathered from previous

a-theoretic studies on this topic26,41, to provide thick description71 and conceptual generalisability72, both of which are important in qualitative research22. Any one conceptual lens can only highlight or


Page 23 of 46

illuminate certain aspects of the data73 and another lens may have highlighted other elements of the issue under focus. For example, we focused on what was said not how it was said61,74. A useful secondary analysis of the data might explore the particular linguistic methods used by FP2 doctors when describing critical workplace experiences and how these influenced their career decisionmaking75,76. We presented doctors’ experiences as short stories in order to capture meaning and understanding in the data and ultimately not to lose key elements of participant experiences. Stories can convey

Fo

the experience of one individual and make it resonate with others47. Through our analytical process

rp

we took care to ensure to share our participants’ stories in such a way that they convey meaning and purpose to the reader61,77. While some researchers quantify qualitative data to highlight patterns

ee

within the data (e.g., Schiffrin 1994)78 we did not do so, instead maintaining a purely qualitative

rr

approach. As mentioned earlier, we could have presented the data as themes, with supporting quotes from a wider number of participants. We tried this, but in our view, this way of presenting

ev

the data did not illuminate clearly the relationships between experiences, perceptions of support

iew

and how these influenced their career decision-making.

We interviewed F2 doctors in two regions of Scotland and took care to recruit a diverse sample,

on

representing doctors of both genders, graduate and school leaver (undergraduates) entrants to medical school, and a mix of doctors from across the UK and Europe, which would be representative

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

and consistent of junior doctors working in the NHS19. However, their views may not be representative of all FP doctors across the UK. We are also aware that the training structure and environments differ across countries. However, the wider literature and anecdotal evidence suggests that the messages from this study are transferable and credible across healthcare contexts14,30,31.


BMJ Open

Our findings have implications for policy, practice and research. We have identified the critical importance of support and feeling valued in F2 doctor’s career intentions. We can infer from the literature that positive social relationships with colleagues79,80, intrinsic motivation81, self-efficacy in one’s skills and abilities79,82 and early exposure to training opportunities that were positively encouraged by senior medical staff5 are important components in terms of committing to further medical training (i.e. applying for speciality training). This reinforces the importance of a supportive clinical learning and working environment, a factor which has been recently highlighted in the

Fo

General Medical Council’s (GMC) most recent document on the state of medical education and training in the UK83. Yet, on the other hand, the data also suggests that there is an interaction

rp

between individual and the workplace environment. This duality merits further investigation.

ee

We presented five unique stories out of a dataset of 21 stories shared by F2 doctors. Our study dealt

rr

with the influence of POS on career intentions. There was some suggestion in the data that POS may be viewed differently by female and male F2 doctors. Other research with this group has shown that

ev

female doctors place higher regard on a supportive working culture than their male counterparts2.

iew

Moreover, international research has shown that female doctors experience considerable challenges within the workplace, including lack of support84-86. However, we do not know if there is a genuine difference between how male and F2 female doctors are supported in the UK workplace, and, of

on

course, our participants were self-selecting. Further research is required to explore this further.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 24 of 46

Second, within medicine there are hierarchical structures and workplace cultures which influence the working and learning experiences of all types and levels of staff. Another potential area for future research would be to seek stories from senior and mid-grade staff as well as more junior staff, to explore POS more widely.

What our study has added is more insight into the important role played by senior staff and team members in terms of exemplifying the culture of the organisation and behavioural norms in terms of


Page 25 of 46

how people are treated by the organisation37. Colleagues can therefore help to improve junior doctors’ perceptions of organisational support through prosocial behaviours like allowing trainee doctors more autonomy, participation in decision making, offering opportunities in professional development, offering rewards and praise for good work1,10,33. This may not always be easy where training competes with service in pressured environments where time and resources are limited83,8789

. However, creating positive working environments does not need to be complicated: consultants

and colleagues knowing the name of their trainee is a simple way to ensure workers feel valued90.

Fo

The norm of reciprocity states that members who feel cared for and supported by the organisation will reciprocate these same patterns of behaviour in return to the organisation25. In other words,

rp

treat your juniors well and they will be happier and more committed to the NHS34,37,41. This simple

ee

rule of behaviour may go some way to encouraging junior doctors to stay in the training pipeline.

iew

ev

rr ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

Contributions JC, PJ and KW obtained the funding for GS’s doctorate. The development of the interviews was led by GS in collaboration with JC. GS prepared the ethics application. GS lead on the literature review. JC supervised the analysis, which was carried out by GS with input from PJ and KW. GS drafted the paper, with JC extensively revising drafts for each section of the paper. All authors contributed to the final paper. The study is guaranteed by the University of Aberdeen. Collaborator Statement

Fo

This project is in collaboration with NHS Education for Scotland. Ethical permission

ee

rp

Ethical permission was granted for this study from the University of Aberdeen College of Life Sciences and Medicine Ethics Research Board (CERB/2015/12/1269, approval granted 25/01/16).

rr

Funding

ev

Our thanks go to NHS Education for Scotland for funding Gillian Scanlan’s programme of work

iew

through the Scottish Medical Education Research Consortium (SMERC) and for funding the open access fee for this paper. Competing Interests

ly

The authors declare no competing interests.

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 26 of 46

Data Sharing All available data can be obtained by contacting the corresponding author (Gillian Scanlan). Acknowledgements Our thanks to all those FP2 doctors who participated in the interviews. Our thanks also to the Foundation Programme Directorate staff in the Scotland Deanery, NHS Education for Scotland for


Page 27 of 46

sending out the email correspondence to the two regions involved in the interviews. No patients or any members of the public were involved in this study.

References 1. Degen C, Weigl M, Glaser J, Li J & Angerer P. The impact of training and working conditions

Fo

on junior doctors’ intention to leave clinical practice. BMC Medical Education 2014, 14:119.

rp

2. Scanlan G, Cleland J, Johnston P, Walker K, Krucien K, Skatun D. What Factors Are Critical to Attracting NHS Foundation Doctors into Speciality or Core Training? A Discrete Choice

ee

Experiment. BMJ Open 2018; 8;e019911.doi:10.1136/bmjopen-2017-019911.

ev

rr 3. Cleland J, Johnston PW, Watson V, Krucien, N, Skatun D. What do UK doctors in training value in a post? A discrete choice experiment. Med Educ. 2016; 50: 189-202.

iew

4. Cleland JA, Johnston P, Watson V, Krucien, N, Skatun D. What do UK medical students value most in their career? A discrete choice experiment. Med Educ. 2017; doi:10.1111/medu.13257.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

5. Pianosi K, Bethune C, Hurley KF. Medical student career choice: a qualitative study of fourthyear medical students at Memorial University, Newfoundland. CMAJ Open. 2016; 4 (2).

6. Maertz CP & Griffeth, R.W.“Eight motivational forces and voluntary turnover: a theoretical synthesis with implications for research”, Journal of Management, 2004; Vol. 30 No. 5, pp. 667-683.


BMJ Open

7. Deutsch T, Honigschmid P, Frese T, Sandholzer H. Early community-based family practice elective positively influences medical students’ career considerations – a pre–postcomparison. BMC Fam Pract 2013;14:24. 8. Akhund S, Shaikh ZA, Kolachi HB. Career related choices of medical students from an International Medical College of Karachi, Pakistan. JLUMHS 2012;11:03. 9. Lachish S, Goldacre MJ, Lambert T. Associations between institutional support, job enjoyment, and attitudes to work in first-year doctors in the UK: national questionnaire

Fo

survey. BMC Med Educ. 2016; 16:151.

rp

10. Boerjan M, Bluyssen SJM, Bleichrodt RP, Van Weel-Baumgarten EM,Van Goor H: Work-

ee

related health complaints in surgical residents and the influence of social support and job-

rr

related autonomy. Med Educ 2010, 44(8):835–844.

iew

ev 11. Ochsmann EB. Thinking About Giving Up Clinical Practice? A Gender-Stratified Approach to Understanding Junior Doctors' Choices. Academic Medicine 2012, 87(1):91–97.

on

12. Rich A, Viney R, Needleman S, Griffin A, Woolf K. You can’t be a person and a doctor’: the

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 28 of 46

work-life balance of doctors in training- a qualitative study. BMJ Open. 2016; 6 :e013897

13. Spooner S, Gibson J, Rigby D, Sutton M, Pearson E, Checkland K. Stick or Twist? Career decision-making during contractual uncertainty for NHS Junior Doctors. BMJ Open. 2017;7: e013756.


Page 29 of 46

14. Malik SZ, Kazmi SZ, & Nadeem N. The Effect of Perceived Organizational Support on Doctors’ Organizational Commitment in Pakistan. The Lahore Journal of Business, 2016; 4(2), 73–92.

15. Madden L, Mathia BD & Madden TM. In good company: The impact of perceived organizational support and positive relationships at work on turnover intentions. Management Research Review, 2015; 38 (3).

Fo

16. Frechette D, Hollenberg D, Shrichand A, Jacob C,Datta I. What’s Really Behind Canada’s

rp

Unemployed Specialists? Too Many, Too Few Doctors? Findings From the Royal College’s

ee

Employment Study. Ottawa, ON:Royal College of Physicians and Surgeons of Canada 2013

rr

17. Gorman DF, Brooks PM. On solutions to doctor shortages in Australia and New Zealand. Med J Aust,2009;190 (3):152–6.

iew

ev

18. Patty A. Forecast oversupply of doctors to hit this year amid calls to halt imports. Sydney Morning Herald.http://www.theage.com.au/business/workplace-relations/forecastoversupply-of-doctors-to-hit-this-year-amid-calls-to-halt-imports-20170103-gtle76. [Accessed11 June 2017.]

ly

19. UKFPO CAREER DESTINATION REPORT 2016

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

www.foundationprogramme.nhs.uk/download.asp?file=Careers_destination_2016.pdf (accessed 8th of March 2017). 20. Gorman DF. Planning healthcare workforces for uncertain futures. Acad Med 2015;90 (4):400–3.


BMJ Open

21. Addicott R, Maguire D, Honeyman M, Jabbal J. Workforce planning in the NHS. The King’s Fund. http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Workforceplanning-NHS-Kings-Fund-Apr-15.pdf. [Accessed 1 August 2016.] 22. Layder D. New Strategies in Social Research: An Introduction and Guide. London: Sage;1998.

23. Eisenberger R, Huntington R, Hutchison S, & Sowa D. Perceived organizational support. Journal of Applied Psychology, 1986; 71(3), 500–507.

Fo

24. Eisenberger R, Armeli S, Rexwinkel B, Lynch PD, & Rhoades L. Reciprocation of perceived

rp

organizational support. Journal of Applied Psychology, 2001; 86(1), 42–51.

ee

25. Gouldner AW. The norm of reciprocity: A preliminary statement. American Sociological Review, 1960; 25(2), 161–178.

rr

26. Rhoades L, Eisenberger R, & Armeli S. Affective commitment to the organization: The

ev

contribution of perceived organizational support. Journal of Applied Psychology, 2001; 86(5), 825–836.

iew

27. Rhoades L, & Eisenberger R. Perceived organizational support: A review of the literature. Journal of Applied Psychology, 2002; 87(4), 698–714.

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 30 of 46

28. Kurtessis JN, Eisenberger R, Ford MT, Buffardi LC, Stewart KA, Adis CS. Perceived Organizational Support: A Meta-Analytic Evaluation of Organizational Support Theory. Journal of Management, 2015; Vol. 43, issue 6, 1854–1884 29. Newman A, Thanacoody R, & Hui W. The effects of perceived organizational support, perceived supervisor support and intra-organizational network resources on turnover intentions: A study of Chinese employees in multinational enterprises. Personnel Review, 2012; 41(1), 56-72.


Page 31 of 46

30. Hao J, Wang J, Liu L, Wu W & Wu H. Perceived Organizational Support Impacts on the Associations of Work-Family Conflict or Family-Work Conflict with Depressive Symptoms among Chinese Doctors. International Journal of Environmental Research and Public Health, 2016; 13, 326. 31. Tekingündüz S, Top M, Tengilimoğlu D & Karabulut E. Effect of organisational trust, job satisfaction, individual variables on the organisational commitment in healthcare services. Total Quality Management & Business Excellence, 2017; 1478-3371.

Fo

32. Maertz CP, Griffeth RW, Campbell NS, & Allen DG. The effects of perceived organizational

rp

support and perceived supervisor support on employee turnover. Journal of Organizational Behavior, 2007; 28(8), 1059–1075.

ee

33. Allen D, Shore L & Griffeth R. “The role of perceived organizational support and supportive

rr

human resource practices in the turnover process”, Journal of Management, 2003; 29(1), 99-

ev

118.

iew

34. Allen DG & Shanock LR. “Perceived organizational support and embeddedness as key mechanisms connecting socialization tactics to commitment and turnover among new employees”, Journal of Organizational Behavior, 2013; 34(3), 350-369.

on

35. Kaplan M, Ogut E, Kaplan A, & Aksay K. The relationship between job satisfaction and

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

organizational commitment: The case of hospital employees. World Journal of Management, 2012; 4(1), 22–29.

36. Arshadi N. The relationships of perceived organizational support (POS) with organizational commitment, in-role performance and turnover intention: Mediating role of felt obligation. Procedia – Social and Behavioral Sciences, 2011; 30, 1103–1108.


BMJ Open

37. Otto K & Mamatoglu N. Why Does Interactional Justice Promote Organizational Loyalty, Job Performance, and Prevent Mental Impairment? The Role of Social Support and Social Stressors, The Journal of Psychology, 2015; 149:2, 193-218. 38. Allen N.J & Meyer J.P. The measurement and antecedents of affective, continuance, and normative commitment to the organization. Journal of Occupational Psychology, 1990 63, 1– 18.

Fo

39. Levinson H. “Reciprocation: the relationship between man and organization”, Administrative

rp

Science Quarterly, 1965; Vol. 9, pp. 370–390.

ee

40. Kalidass A & Bahron A. The Relationship between Perceived Supervisor Support, Perceived

rr

Organizational Support, Organizational Commitment and Employee Turnover Intention.

ev

International Journal of Business Administration, 2015; 6(5).

iew

41. Eisenberger R & Stinglhamber F. Perceived Organizational Support: Fostering Enthusiastic

on

and Productive Employees, American Psychological Association, Washington, DC. 2011.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 32 of 46

42. Buddeberg-Fischer B, Dietz C, Klaghofer R, Buddeberg C: Swiss residents' arguments for and against a career in medicine. BMC Health Serv Res, 2006; 6(1):98.

43. Dutton J.E & Ragins BR. (Eds). Exploring Positive Relationships at Work: Building A Theoretical and Research foundation, Lawrence Erlbaum Associates, Mahwah, NJ. 2007.


Page 33 of 46

44. Filipova AA. “Relationships among ethical climates, perceived organizational support, and intent-to-leave for licensed nurses in skilled nursing facilities”. Journal of Applied Gerontology, 2011; 30 (1), 44-66. 45. Crotty M. The Foundations of Social Research. 2003. Sage: London. 46. Trần Văn Kham. Overview of Social Constructionism and Its Potential Applications for Social Work Education and Research in Vietnam. Journal of Social Sciences and Humanities, 2013; Vol. 29, No. 4, 30-37.

Fo

47. Bamburg M. Stories: Big or Small: Why do we care? Narrative Inquiry, 2006, 16 (1), 139-147.

rp

48. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006; 3 (2): 77-101.

rr

ee

49. King, N, Horrocks Ch. 2010. Interviews in Qualitative Research. London: Sage Publications

ev

50. Lincoln YS, Guba EG. Naturalistic Enquiry. 1985. Beverley Hills, CA: Sage.

iew

51. McMillan W. Theory in healthcare education research: the importance of worldview. In: Cleland JA, Durning SJ, eds. Researching Medical Education. Oxford: Wiley 2015; 15-23. 52. Varpio L, Ajjawi R, Monrouxe LV, O’Brien, Rees CE. Shedding the cobra effect:

on

problematising thematic emergence, triangulation, saturation and member checking. Medical Education 2017; 51: 40-50

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

53. Monrouxe L.V, Rees C.E, Lewis N.J, & Cleland J. Medical educators’ social acts of explaining passing underperformance in students: a qualitative study. Adv in Health Sci Educ, 2011, 16, 239-252. 54. Dennis A.A, Foy M.J, Monrouxe L.V, & Rees C.E. Exploring trainer and trainee emotional talk in narrative about workplace-based feedback processes. Adv in Health Sci Educ, 2017, 23 (1), 75-93. 33 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

55. Kendall J.E, and Kendall K.E. STORYTELLING AS A QUALITATIVE METHOD FOR IS RESEARCH: HERALDING THE HEROIC AND ECHOING THE MYTHIC. Australasian Journal of Information Systems, 2012, Volume 17 (2). 56. Bruner J.S. (1990) Acts of Meaning, Harvard University Press, Cambridge, MA. 57. Frohman D. (2006) “Leadership Under Fire,” Harvard Business Review, Vol 84 No 12, 12, pp 124-131.

Fo

58. Flick U, Kardorff EV, & Steinke I. A companion to qualitative research. London: Sage. 2004.

rp

59. Bamburg M, & Demuth C. Narrative Inquiry: An Interview with Michael Bamberg. Eur J Psychol, 2016, 12 (1), 14-28.

ee

60. Stinglhamber F, & Vandenberghe C. Organizations and supervisors as sources of support and

rr

targets of commitment: A longitudinal study. Journal of Organizational Behavior,2003; 24, 251-270.

ev

61. Bailey P.H & Tilley S. Storytelling and the interpretation of meaning in qualitative research.

iew

Journal of Advanced Nursing, 2002; 36 (8), 574-583.

62. Sparr JL & Sonnentag S. Fairness perceptions of supervisor feedback, LMX, and employee

on

well-being at work. European Journal of Work and Organizational Psychology, 2008; 17, 198–225.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 34 of 46

63. Wang X, Liao J, Xia D, & Chang T. The impact of organizational justice on work performance: Mediating effects of organizational commitment and leader-member exchange. International Journal of Manpower, 2010; 31, 660–677.


Page 35 of 46

64. Spell CS, & Arnold TJ. A multi-level analysis of organizational justice climate, structure, and employee mental health. Journal of Management, 2007;33, 724–751.

65. Eisenberger R, Stinglhamber F, Vandenberghe C, Sucharski IL, & Rhoades L. Perceived supervisor support: Contributions to perceived organizational support and employee retention. Journal of Applied Psychology, 2002; 87(3), 565–573. 66. Billett, S 2001 Coparticipation at work: affordance and engagement. In fenwick T (ed)

Fo

Sociocultural perspectives on learning through work (vol 92). Jossey Bass/Wiley, San Francisco.

rp

67. Eraut M. Informal learning in the workplace. Stud Contin Educ. 2004;26(2):247-273.

ee

68. Skipper M, Nøhr SB, Jacobsen TK, Musaeus P. “Organisation of workplace learning: a case

rr

study of paediatric residents’ and consultants’ beliefs and practices.” Adv Heal Sci Educ. 2015; 21:677–694.

iew

ev

69. van de Wiel MWJ, Van den Bossche P, Janssen S, Jossberger H. Exploring deliberate practice in medicine: how do physicians learn in the workplace? Adv Health Sci Educ Theory Pract. 2011;16(1):81-95.

on

70. Sargeant J, Mann K, Sinclair D, et al. Learning in practice: experiences and perceptions of high scoring physicians. Acad Med. 2006;81(7):655-660.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

71. Geertz C. The Interpretation of Cultures: Selected Essays. Fontana: London. 1993

72. Strauss A & Corbin J. Basics of Qualitative Research Techniques and Procedures for Developing Grounded Theory (2nd edition). Sage Publications: London. 1998


BMJ Open

73. Bordage G. Conceptual frameworks to illuminate and magnify. Medical Education. 2009 43: 312-319. 74. Reissman C.K. Narrative Analysis. In: Narrative, Memory & Everyday Life. University of Huddersfield, Huddersfield, 2005, pp 1-7. 75. Labov W, & Waletzky J. Narrative analysis. Essays on the Verbal and Visual Arts, Ed. J. Helm, 12-44. Seattle: U. of Washington Press. 1967

Fo

76. Labov W. Some further steps in narrative analysis. Journal of Narrative and Life History, 1997,7, 395-415.

rp

77. Rooney T, Lawlor K, Rohan E “Telling Tales; Storytelling as a methodological approach in

ee

research”. The Electronic Journal of Business Research Methods 14 Issue 2 2016, (pp147-156

rr

78. Schiffrin, D. (1994). Approaches to discourse. Oxford: Blackwell.

ev

79. Bandura A. Cultivate self-efficacy for personal and organizational effectiveness. Oxford: Blackwell. 2000

iew

80. Karademas EC. "Self-efficacy, social support and well-being. The mediating role of optimism". Personality and Individual Differences, 2006; 40, 1281-1290.

on

81. Eisenberger R, Rhoades L & Cameron J. “Does pay for performance increase or decrease

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 36 of 46

perceived self-determination and intrinsic motivation?”, Journal of Personality and Social Psychology, 1999; Vol. 77 No. 5, pp. 1026-1040.

82. Lunenburg FC. Self-Efficacy in the Workplace: Implications for Motivation and Performance. International Journal of Management, Business, and Administration, 2011; 14,1.


Page 37 of 46

83. General Medical Council (GMC). The state of medical education and practice in the UK. 2011. http://www.gmc-uk.org/State_of_medicine_Final_ web.pdf_44213427.pdf. [Accessed 28 August 2016.] 84. Adesoye T, Mangurian C, Choo E.K. Perceived Discrimination Experienced by Physician Mothers and Desired Workplace Changes. JAMA Intern Med. 2017;177(7):1033-1036. doi:10.1001/jamainternmed.2017.1394. 85. Bismark M, Morris J, Thomas L, et al Reasons and remedies for under-representation of

Fo

women in medical leadership roles: a qualitative study from Australia. BMJ Open 2015;5:

rp

e009384. doi:10.1136/ bmjopen-2015-009384

ee

86. Nomura K, Yamazaki Y, Gruppen LD, et al. The difficulty of professional continuation among female doctors in Japan: a qualitative study of alumnae of 13 medical schools in Japan. BMJ

rr

Open 2015;5: e005845. doi:10.1136/ bmjopen-2014-005845

ev

87. Busari JO, Koot BG. Quality of clinical supervision as perceived by attending doctors in

iew

university and district teaching hospitals. Med Educ 2007;41(10):957–64. 88. Henning MA, Shulruf B, Hawken SJ, Pinnock R. Changing the learning environment: the medical student voice. Clin Teach 2011;8 (2):83–7.

on

89. Turner TL, Fielder E, Ward MA. Balancing service and education in residency training. A logical fallacy. JAMA Pediatr 2016;170 (2):101–2.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

90. Cleland J, Roberts R, Kitto S, Strand P, & Johnston P. Using paradox theory to understand responses to tensions between service and training in general surgery. Medical Education, 2017, doi: 10.1111/medu.13475.


BMJ Open

Box 1- Daniel’s Story 1

I think senior support at times was a huge factor for us, particularly in A&E. I'm never on shift without 2 somebody who's at least a senior registrar or a consultant. So I've never, ever had any issues. Sometimes 3 getting them it's a little bit difficult but it's just the nature of the job…they are probably seeing a patient, but I just go in and grab 4them and call them out if I need 4them, you know. So if I need access to them. 5 When I went to A&E, my educational supervisor in A&E, she's very proactive. She's super. We did a lot of 6 discussion around how I manage patients, so she'll call the patients up that I've seen X number of weeks ago, and 7we go through and look at my documentation, see how I managed it. And it's not criticising me. I mean if it is 8critical, it's constructive criticism. So I think that's a huge, huge aspect of learning as a junior. 9 And that's the first time I've had a supervisor that has been that enthusiastic, and that makes a hell of a 10 difference … She even creates opportunities for you…. And then that leads into feeling valued’ 11 SP1: Difference that you feel more supported I take it? 12 SP2: Yeah. She even creates opportunities for you. She'll go out of her way to sort things. I got a taster 13 week in…Anaesthetics I got, long term advanced trauma life support. If they take an interest in you it makes it… 14 SP1: So you've obviously mentioned getting; cracking on and getting on with it. So you've applied for speciality 15training or core medical training at FY2? 16 SP2: Yes, I applied for anaesthetics. 17 SP1: Anaesthetics, okay. And why were you attracted to anaesthetics? 18 SP2: I've done it and I liked it… When you see what they do and how they... How well-supported they are as 19 a junior. So they're probably the best trained in terms of consultants with juniors. So you're one-on-one, 20 junior and consultant most of the time as an anaesthetic trainee. The training you get is... You know, 21 they're able to deal with nearly everything, in terms of managing patients. That's what attracted me to it as well is the quality of 22training you're going to get. 23 SP1: The quality and the kind of support that you're getting as well? 24 SP2: Yes, exactly

Box 2 Steven’s Story

…when I got out I was actually doing the job because I could have easily just been given rubbish tasks 2to do for 4 months but I was encouraged to take part and work with a wide variety of consultants, see 3how they worked and becoming, like, familiar. 4 I felt much more confident, at the end of the four months, that I could assess, you know, intensive care 5 patients and make basic decisions. Nothing fancy but at least hold the fort for like an hour or so. 6 7 Having the opportunity to do intensive care and anaesthetics as my first FY2 job which… because I was 8 interested in it and I was given that by the programme director; he organised that, so I had experience in that before I applied, which I was very grateful for. Having done that I knew that was 9what I wanted to do and so I applied. 10 So I was very much still thinking do I want to go down the emergency medicine route, do I want to go 11 down, you know… I want to do intensive care. Anaesthetics is interesting but I didn’t think I want to do 12it. Didn’t get an A and E job but I got an intensive care job and then, I think, as I met the people with 13the 14 emergency medicine doctors; I learned a bit more about how I liked to work…I think people talk about 15 personalities and I thought maybe my personality wasn’t actually quite aligned to emergency medicine but I really enjoyed anaesthetics. 16 17 I got to work with the anaesthetist and thought actually I could fit in here and that’s an opportunity I might 18 not have had and if, say, anaesthetics… No say ICU would be my last job, I might not have been so confident. Even if I’d done it as FY2 but we’re starting it in April instead of August. I might not have 19been confident; I might have taken it… 20 SP1 So that almost shaped your decision then if you say that happening even shaped your decision to 21have the confidence to do that? 22 SP2: Yeah, yeah, I might have waited another year to do that instead of I’ll see how I find it at the end 23of 24 the year. I’ll take the year out locum and then apply once I know what I want to do. It’s difficult to know what I would if things had been different. 25 26 I remember talking to friends and I’d always… As I said, I thought I wanted to do an acute specialty, maybe 27 emergency medicine, maybe intensive care, and I’d enjoyed anaesthetics. I was so well supported by all the

iew

1

ev

rr

ee

rp

Fo

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 38 of 46


Page 39 of 46

different consultants and I enjoyed the hands on… You know, it felt right and 28having the opportunity to do 29 that I knew that this is what I want to do. I’ve been asked, as I’m sure every junior doctor or medical student is asked for a few years, what kind of doctor do you want to be? 30 I never had an answer and it was really August, and it came quite suddenly, it was kind of like it’s a 31 32 lightbulb moment because just thinking a year ago I was still between two or three specialties. As soon 33 as I did that I was like, yeah, I’ll do this. This is great; I can be an anaesthetist… This is what I enjoy which some people go to medical school knowing they want to be a specific type of surgeon or a 34GP. It took me until I was actually doing that job as a FY2 to say this is for me. 35 SP1: So would it be fair to say almost that positive experience of getting an opportunity to practice… 36almost helped along that pathway as well with prior to making a decision. 37 SP2: Definitely. As I said I might not have applied to [ACCS] training… 38 SP2: Yes, for the next… Well, if I get to retire. That… It’s a decision that I don’t think I would’ve made. 39 40 Actually thinking back to making that decision, knowing how confident I was that I enjoyed anaesthetics; it 41 still felt like a big thing to click that button and apply for that job. I most definitely wouldn’t have done that if I hadn’t had that experience in anaesthetics.

Fo

Box 3- Abigail’s Story 1

rp

Yeah, so as a whole, I found the foundation experience really disappointing. I’ve not enjoyed it all as a profession, or as a job. I felt that you’re extremely undervalued as an individual, and as a professional. 3 And there’s huge neglect of training for foundation doctors, especially at FY1 level. I don’t think that 4you’re respected or considered to be a practising clinician. 5 I think there’s not much in the way of recognition for the work that you do. And I think that you do a lot 6of legwork for a lot of other people. And people aren’t very thankful of that. 7 8 I don’t think that you’re treated well by other members of healthcare professionals within the teams. And 9 that makes your role feel devalued as well. You feel devalued in that sense that other people don’t treat you very nicely at all. 10 As a whole…as a whole it’s really, I found it very disheartening. And I had never expected to be treated 11 so badly as a professional. 12 Bearing in mind that this is your first ever experience of a job. And often, medical students or medics 13don’t necessarily work much before they go to university. This is the first time you ever experience 14working life. And those that work within the institution should know better that it’s a very, very difficult 15job. 16 And that on the whole, they’re treated very badly. But I don’t think that makes any difference. And I 17don’t 18 think it means that people make any effort at all to be inviting, to be encouraging, to be supportive of the 19 fact that you are a young professional that has no experience working in a professional environment. And I think that was one of the biggest things that I found so difficult. 20 21 I don’t think if you went to any other institution, any other organization, anywhere as a professional, or in 22 any other business they would make you feel crap in the first… You know, having that first experience, you know, I mean, you know what I mean to work somewhere in the first year. 23 You just feel totally disengaged, and very down trodden. And you feel undervalued. 24 I found it really disappointing. Like, I’ve spent years training to do this job. And I really, really wanted 25to do it. I’ve always wanted to be a doctor. And I got here, and I’ve just found it devastating. I’ve 26really been so disheartened, and just put off with the profession as a whole just because the way in 27which the work is’. 2

iew

ev

rr

ee

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Box 4- Gemma’s Story 1

And then other times, when you have, you don’t have the senior support that you need, for whatever 3 reason; they’re caught up doing something else, or… And then you’re, you feel out of your depth. Especially 4 when you’re SHO, and the reg is the next tier and if they’re in theatre or they’re with another sick patient, 5 then you, kind of, feel a bit like you’re out of your depth sometimes. Which is sometimes fun if you manage to sort it out, but sometimes a bit overwhelming and exhausting. 6 I can find things quite upsetting that I probably would normally be able to deal with quite well. Things 7about, you know, outside of work would affect me more, or… Yes, just feel a bit… Sometimes if you’ve 8not… You’ve literally been at work, slept, and been at work for seven days; you’ve had no social 9interaction at all outside of work, and that also gets you down. Because, you know, you need to do, you 10see friends and do fun things 2


BMJ Open

that will let you relax, to be able to maintain a, kind of, healthy 11emotional state. 12 13 I did have a case, when I was in paediatrics, where I didn’t feel supported at all by my seniors. In fact, the 14 opposite, by the consultants, and it really upset me and got me down and affected me for months, so… And at the end of that, I thought, no, I don’t want to. I decided to take a year out from that. 15 There was a patient that became seriously unwell, that I didn’t know that the baby was unwell, and then 16 17 got, kind of, blamed for it afterwards, despite the fact that I tried to escalate it and they didn’t really, like, 18 want to take any kind of responsibility. And I tried to get some help and no one would come to help. And then I, kind of, got blamed for it and not supported through it, not debriefed or… I just, kind 19of, felt like it was my fault and then I had to kind of process it and deal with it on my own, rather than 20having… 21 We have our clinical and educational supervisors that are meant to help us through those, like, the 22 emotional aspects of our work, as well as all the practical aspects of just getting through the course. But 23it, it all, they’re all consultants that take on that role, so… And obviously, every personality differs, and 24 everyone… So I was just unlucky that all of the consultants there didn’t really seem to care about that. 25 And there wasn’t anyone that I felt like I could ask.

Box 5- Clare’s Story 1

rp

Fo

Erm I think now, the longer I work for, not having any control over my annual leave, my days off, my 2time off, is really starting to really annoy me. So my next rota, for example, I have just been informed, 3you have three weeks’ annual leave, this is when they are, you can’t swap them, you can’t move them, 4tough. I think that that is a disgrace. 5 6 The number of hours I have worked to be told, you’re not allowed to go on a family holiday that you’ve 7 booked. You’re not allowed… I’ve been told I’m not allowed to go to a funeral before. I’ve been told I’m not 8 allowed time off when I’m ill. That… I would have said, is the worst thing. I just, I don’t think it’s fair, and I think that bothers me more and more, I think, as time goes on. 9 10 I think, particularly my, like, having been in {Community hospital} now for 12 weeks, the thought of coming 11 back to X hospital…it’s horrifying. I just am dreading it. I’m absolutely dreading having to come back. And when I saw the rota… Whichever idiot person made the rota, who has never worked 12as a doctor and has no idea what they’re doing… I was almost in tears, looking, and just thinking, oh 13God, half nine. So, a quarter of all of my shifts, I finish at half past nine at night, which means I don’t 14get home until after ten, which means I won’t see my partner for the next four months. That, I just… 15That’s the worst bit, I think. 16 I would have said, there were certain bits that have made me think, I’m 100% positive I don’t want to 17 continue working in this hospital. And I would have said… My second job in the FY1 was {a surgical 18 19 specialty}…There was meant to be two FY1s and two FY2s. The FY2s were on the registrar rota, which was 20 hell on earth for them, and therefore I was the only FY1, and there were no FY2s because they were on the reg rota. 21 And I was put in horrific, horrific situations...there was one horrendous weekend where I had three 22 people in the HDU, had sixty patients, and then I had another four beds due where I had four people 23that were really sick with pneumonia. And I hadn’t had a medical job, and I didn’t know what I was 24doing, and I have never in my life felt so overwhelmed, and I just… I hated it, I absolutely hated it. I 25didn’t get support; 26 I’d phone the registrar to come in, they came in in the morning for an hour, did a ward round and just left. And I was left on my own for a full weekend. 27 28 I’ve got GP training; I’ve accepted a GP position… The thought of actually having to spend any more time 29 in that hospital is just horrifying, but I think…So the thought of having to do six, seven years to consultant, there’s no way. There’s literally no way I would do it. 30 Management don’t know who I am, don’t know what I’m about. And if I raise a concern, I think they 31see that you’re a hassle, it’s a problem, as opposed to, you’re a valued team member that they think 32is worth being there. I don’t, yes, I don’t feel valued in that capacity.

iew

ev

rr

ee

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 40 of 46


Page 41 of 46

Figure Legends: Title: The Theory of Perceived Organizational Support Figure one: Perceived Organizational Support and its components. Title: Personal Stories Shared by F2 Doctors. Box 1: Daniel’s Story Box 2: Steven’s Story Box 3: Abigail’s Story Box 4: Gemma’s Story Box 5: Clare’s Story

iew

ev

rr

ee

rp

Fo ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open


BMJ Open

iew

ev

rr

ee

rp

Fo 198x148mm (300 x 300 DPI)

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 42 of 46


Page 43 of 46

Table 1 Consolidated criteria for reporting qualitative studies (COREQ): 32-item checklist No Item Guide questions/description Domain 1: Research team and reflexivity Personal Characteristics 1. Interviewer/facilitator Which author/s conducted the interview or focus group? Gillian Scanlan 2. Credentials

Fo

What were the researcher's credentials? PhDs with extensive experience in medical education research, medical educators plus a PhD candidate. 3. Occupation

rp

What was their occupation at the time of the study?

ee

Working in medical education and academia. The potential impact of these occupations on the research and data analysis is clearly stated.

rr

4. Gender Was the researcher male or female? Female 5. Experience and training

iew

ev

What experience or training did the researcher have? Being trained as part of a PhD candidacy. Relationship with participants

on

6. Relationship established- Was a relationship established prior to study commencement? No, interviews were conducted with volunteers.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

7. Participant knowledge of the interviewer -What did the participants know about the researcher? e.g. personal goals, reasons for doing the research The reasons for conducting this research were explained in information sheets provided to volunteers, explaining this research was part of a wider PhD project looking at the experiences of foundation programme doctors. All information was reviewed by the ethics committee before the study begun. 8.Interviewer characteristics What characteristics were reported about the interviewer/facilitator? e.g. Bias, assumptions, reasons and interests in the research topic The academic reasons for conducting the research and the place/gap in the literature is clearly explained. All interviews were undertaken by the first author (GS) to ensure continuity. We


BMJ Open

explain within the text that the team was made of up psychology and medical backgrounds. We reflected on how different disciplinary backgrounds may have shaped the co-construction of the data. Domain 2: study design Theoretical framework 9. Methodological orientation and Theory What methodological orientation was stated to underpin the study? Epistemological orientation of social constructionism and the theoretical framework of perceived organisational support.

Fo

Participant selection

rp

10. Sampling

How were participants selected? e.g. purposive, convenience, consecutive, snowball

ee

Volunteers responded to an email sent out by foundation programme directors in two regions of Scotland. The volunteers varied in backgrounds, gender, location of schooling and medical degree training. 11. Method of approach

ev

rr

How were participants approached? e.g. face to- face, telephone, mail, email Volunteers then emailed back to the researcher and interviews were arranged. 12. Sample size How many participants were in the study? 21 participated in this study.

iew

13. Non-participation

on

How many people refused to participate or dropped out? Reasons?

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 44 of 46

We originally had 23 initially volunteer but two interviews could not be arranged within the timescale of the study. Setting 14. Setting of data collection Where was the data collected? e.g. home, clinic, workplace Interviews were conducted at a place convenient for the interviewee. The interviewee’s comfort was of critical importance to this research, and thus interviews took place outside place of work. 15. Presence of nonparticipants


Page 45 of 46

Was anyone else present besides the participants and researchers? No. 16. Description of sample What are the important characteristics of the sample? e.g. demographic data, date The data provides evidence that the sample includes a good range of foundation doctors, personal characteristics are reported within the results section. Data collection 17. Interview guide Were questions, prompts, guides provided by the authors? Was it pilot tested?

Fo

The interview guide was devised following a review of the relevant literature and the authors’ experience in teaching doctors at the same stage of training. Based on the fact this study is part of a wider PhD project, this information will be included within a larger thesis. The guide was piloted, again by doctors at the same stage of training but not participants in the research.

ee

18. Repeat interviews

rp

Were repeat interviews carried out? If yes, how many? No.

ev

19. Audio/visual recording

rr

Did the research use audio or visual recording to collect the data? Audio-recording 20. Field notes

iew

Were field notes made during and/or after the interview or focus group? Yes 21. Duration

ly

What was the duration of the interviews or focus group?

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

The median interview length of interviews was 30.26 minutes (from 18 minutes to 52 minutes). 22. Data saturation Was data saturation discussed? Yes discussed within the research team. 23. Transcripts returned Were transcripts returned to participants for comment and/or correction? No Domain 3: analysis and findings Data analysis 24.Number of data coders


BMJ Open

How many data coders coded the data? There was one data coder, but the team contributed to coding and discussion of the analysis. 25. Description of the coding tree Did authors provide a description of the coding tree? Yes, the material was coded according to the Perceived Organisational Support model once it was identified to be a good fit with the emerging data. 26. Derivation of themes Were themes identified in advance or derived from the data? Induced from the data. 27. Software

Fo

What software, if applicable, was used to manage the data? Nvivo.

28. Participant checking

ee

rp

Did participants provide feedback on the findings? No.

ev

29. Quotations presented

rr

Were participant quotations presented to illustrate the themes / findings? Was each quotation identified? e.g. participant number Yes. 30. Data and findings consistent

iew

Was there consistency between the data presented and the findings? Yes.

ly

No Item Guide questions/description

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 46 of 46

31. Clarity of major themes- Were major themes clearly presented in the findings? Yes. 32. Clarity of minor themes Is there a description of diverse cases or discussion of minor themes?

We have presented diverse cases. Our analytical framework illuminates certain aspects of the data, and we have been explicit as to the strength and limitations of using a theory-driven approach in the discussion. We explored experiences and perceptions. We have no concrete way of linking these with actual career behaviour.
