Using paradox theory to understand responses to tensions between service and training in general surgery

Bridging School and Practice? Barriers to the Integration of 'Boundary Objects' for Learning and Assessment in Clinical Nursing Education

Introduction

In clinical health professions education, portfolios, assignments and assessment standards are used to enhance learning. When these tools fulfill a bridging function between school and practice, they can be considered 'boundary objects'. In the clinical setting, these tools may be experienced as time-consuming and lacking value. This study aimed to investigate the barriers to the integration of boundary objects for learning and assessment from a Cultural-Historical Activity Theory (CHAT) perspective in clinical nursing education.

Methods

Nineteen interviews and five observations were conducted with team leads, clinical educators, supervisors, students, and teachers to obtain insight into intentions and use of boundary objects for learning and assessment. Boundary objects (assessment standards, assignments, feedback/reflection/patient care/development plan templates) were collected. The data collection and thematic analysis were guided by CHAT.

Results

Barriers to the integration of boundary objects included: a) conflicting requirements in clinical competency monitoring and assessment, b) different application of analytical skills, and c) incomplete integration of boundary objects for self-regulated learning into supervision practice. These barriers were amplified by the simultaneous use of boundary objects for learning and assessment. Underlying contradictions included different objectives between school and practice, and tensions between the distribution of labor in the clinical setting and school's rules.

Discussion

School and practice have both convergent and divergent priorities around students' clinical learning. Boundary objects can promote continuity in learning and increase students' understanding of clinical practice. However, effective integration requires for flexible rules that allow for collaborative learning around patient care.

Unveiling the paradoxes of implementing post graduate competency based medical education programs

PURPOSE

Competency-based medical education (CBME) has gained prominence as an innovative model for post-graduate medical education, yet its implementation poses significant challenges, especially with regard to its sustainability. Drawing on paradox theory, we suggest that revealing the paradoxes underlying these challenges may contribute to our understanding of post graduate competency-based medical education (PGCBME) implementation processes and serve as a first-step in enhancing better implementation. Thus, the purpose of the current study is to identify the paradoxes associated with PGCBME implementation.

METHOD

A qualitative study was conducted, as part of a larger action research, using in-depth semi-structured interviews with fellows and educators in eight Neonatal wards.

RESULTS

Analysis revealed that the PGCBME program examined in this study involves three different levels of standardization, each serving as one side of paradoxical tensions; (1) a paradox between the need for standardized assessment tools and for free-flow flexible assessment tools, (2) a paradox between the need for a standardized implementation process across all wards and the need for unique implementation protocols in each ward; and 3) a paradox between the need for a standardized meaning of competency proficiency and the need for flexible and personal competency achievement indicators.

CONCLUSIONS

Implementing PGCBME programs involves many challenges, some of which are paradoxical, i.e. two contradictory challenges in which solving one challenge exacerbates another. Revealing these paradoxes is important in navigating them successfully.

To prove or improve? Examining how paradoxical tensions shape evaluation practices in accreditation contexts

INTRODUCTION

Although programme evaluation is increasingly routinised across the academic health sciences, there is scant research on the factors that shape the scope and quality of evaluation work in health professions education. Our research addresses this gap, by studying how the context in which evaluation is practised influences the type of evaluation that can be conducted. Focusing on the context of accreditation, we critically examine the types of paradoxical tensions that surface as evaluation-leads consider evaluation ideals or best practices in relation to contextual demands associated with accreditation seeking.

METHODS

Our methods were qualitative and situated within a critical realist paradigm. Study participants were 29 individuals with roles requiring responsibility and oversight on evaluation work. They worked across 4 regions, within 26 academic health science institutions. Data were collected using semi-structured interviews and analysed using framework and matrix analyses.

RESULTS

We identified three overarching themes: (i) absence of collective coherence about evaluation practice, (ii) disempowerment of expertise and (iii) tensions as routine practice. Examples of these latter tensions in evaluation work included (i) resourcing accreditation versus resourcing robust evaluation strategy (performing paradox), (ii) evaluation designs to secure accreditation versus design to spur renewal and transformation (performing-learning paradox) and (iii) public dissemination of evaluation findings versus restricted or selective access (publicising paradox). Sub-themes and illustrative data are presented.

DISCUSSION

Our study demonstrates how the high-stakes context of accreditation seeking surfaces tensions that can risk the quality and credibility of evaluation practices. To mitigate these risks, those who commission or execute evaluation work must be able to identify and reconcile these tensions. We propose strategies that may help optimise the quality of evaluation work alongside accreditation-seeking efforts. Critically, our research highlights the limitations of continually positioning evaluation purely as a method versus as a socio-technical practice that is highly vulnerable to contextual influences.

Context matters in curriculum reform: An analysis of change in surgical training

INTRODUCTION

Education and training reforms are typically devised by accreditation bodies and rolled out nationally. This top-down approach is positioned as contextually independent, yet context is highly influential in shaping the impact of change. Given this, it is critical to consider how curriculum reform plays out as it meets local settings. We have therefore used a national-level curriculum reform process of surgical training, Improving Surgical Training (IST), to examine the influence of context in IST implementation across two UK countries.

METHODS

Adopting a case study approach, we used document data for contextualisation purposes and semi-structured interviews with key stakeholders across multiple organisations (n = 17, plus four follow-up interviews) as our main source of data. Initial data coding and analysis were inductive. We followed this with a secondary analysis using Engeström's second-generation activity theory nested within an overarching framework of complexity theory to help tease out some key elements of IST development and implementation.

RESULTS

The introduction of IST into the surgical training system was historically situated within a landscape of previous reforms. IST's aims collided with existing practices and rules, thus creating tensions. In one country, the systems of IST and surgical training came together to some extent, mostly due to processes of social networks, negotiation and leverage nested in a relatively cohesive setting. These processes were not apparent in the other country, and instead of transformative change, the system contracted. Change was not integrated, and the reform was halted.

CONCLUSIONS

Our use of a case study approach and complexity theory deepens understanding of how history, systems and contexts interact to facilitate or inhibit change within one area of medical education. Our study paves the way for further empirical work examining the influence of context in curriculum reform, and thus determining how best to bring about change in practice.

Scratching beneath the surface: How organisational culture influences curricular reform

INTRODUCTION

Curricular reform is often proposed as the means to improve medical education and training. However, reform itself may not lead to noticeable change, possibly because the influence of organisational culture on change is given insufficient attention. We used a national reform of early-years surgical training as a natural opportunity to examine the interplay between organisational culture and change in surgical education. Our specific research question was: in what ways did organisational culture influence the implementation of Improving Surgical Training (IST)?

METHODS

This is a qualitative study underpinned by social constructivism. Interviews were conducted with core surgical trainees (n = 46) and their supervising consultants (n = 25) across Scotland in 2020-2021. Data coding and analysis were initially inductive. The themes indicated the importance of many cultural factors as barriers or enablers to IST implementation. We therefore carried out a deductive, secondary data analysis using Johnson's (1988) cultural web model to identify and examine the different elements of organisational culture and their impact on IST.

RESULTS

The cultural web enabled a detailed understanding of how organisational culture influenced IST implementation as per Johnson's six elements-Rituals and Routines (e.g. departmental rotas), Stories (e.g. historical training norms and culture), Symbols (e.g. feedback mechanisms, visibility and value placed on education), Power Structures (e.g. who has the power in local contexts), Organisational Structures (e.g. relationships and accountability) and the Control System (e.g. consultant job plans and service targets)-and how these interact. However, it did not shed light on the influence of exogenous events on change.

CONCLUSION

Our data reveal cultural reasons why this curricular reform met with varying degrees of success across different hospital sites, reinforcing that curricular reform is not simply about putting recommendations into practice. Many different aspects of context must be considered when planning and evaluating change in medical education and training.

"It's making me think outside the box at times": a qualitative study of dynamic capabilities in surgical training

Craft specialties such as surgery endured widespread disruption to postgraduate education and training during the pandemic. Despite the expansive literature on rapid adaptations and innovations, generalisability of these descriptions is limited by scarce use of theory-driven methods. In this research, we explored UK surgical trainees' (n = 46) and consultant surgeons' (trainers, n = 25) perceptions of how learning in clinical environments changed during a time of extreme uncertainty (2020/2021). Our ultimate goal was to identify new ideas that could shape post-pandemic surgical training. We conducted semi-structured virtual interviews with participants from a range of working/training environments across thirteen Health Boards in Scotland. Initial analysis of interview transcripts was inductive. Dynamic capabilities theory (how effectively an organisation uses its resources to respond to environmental changes) and its micro-foundations (sensing, seizing, reconfiguring) were used for subsequent theory-driven analysis. Findings demonstrate that surgical training responded dynamically and adapted to external and internal environmental uncertainty. Sensing threats and opportunities in the clinical environment prompted trainers' institutions to seize new ways of working. Learners gained from reconfigured training opportunities (e.g., splitting operative cases between trainees), pan-surgical working (e.g., broader surgical exposure), redeployment (e.g., to medical specialties), collaborative working (working with new colleagues and in new ways) and supervision (shifting to online supervision). Our data foreground the human resource and structural reconfigurations, and technological innovations that effectively maintained surgical training during the pandemic, albeit in different ways. These adaptations and innovations could provide the foundations for enhancing surgical education and training in the post-pandemic era.

How do foundation year and internship experience shape doctors' career intentions and decisions? A meta-ethnography

PURPOSE

Foundation years or internships are an important period for junior doctors to apply their knowledge and gain clinical competency. Experiences gained during the foundation years or internships are likely to inform newly qualified doctors' opinions about how they want to continue their career. We aimed to understand how medical doctors' internship experiences influence their career intention/decision.

METHODS

We conducted qualitative evidence synthesis using meta-ethnography. We searched six electronic bibliographic databases for papers published between 2000-2020 and included papers exploring how foundation years or internship experiences shape doctors' career intention/decisions, including in relation to migration, public/private/dual practice preference, rural/urban preference, and specialty choice. We used the GRADE-CERQual framework to rate confidence in review findings.

RESULTS

We examined 23 papers out of 6085 citations screened. We abstracted three high-level inter-related themes across 14 conceptual categories: (1) Deciding the personal best fit both clinically and in general (which option is 'more me'?) through hands-on and real-life experiences (2) Exploring, experiencing and witnessing workplace norms; and (3) Worrying about the future in terms of job market policies, future training and professional development opportunities. Confidence in findings varied but was rated high in 8 conceptual categories.

CONCLUSIONS

Our meta-ethnographic review revealed a range of ways in which internship experience shapes medical doctors' career intentions/decisions allowing us to produce a broad conceptual model of this phenomenon. The results highlight the importance of ensuring sufficient, positive and inspiring clinical exposure, improving workplace environment, relationship and culture, refraining from undermining specific specialities and communicating contractual and job market policies early on to young doctors, in order to attract doctors to less popular specialties or work locations where they are most needed. We propose our conceptual model should be further tested in new research across a range of contexts.

Prioritizing Clinical Teaching Excellence: A Hidden Curriculum Problem

There have been many initiatives to improve the conditions of clinical teachers to enable them to achieve clinical teaching excellence in Academic Medical Centres (AMC). However, the success of such efforts has been limited due to unsupportive institutional cultures and the low value assigned to clinical teaching in comparison to clinical service and research. This forum article characterizes the low value and support for clinical teaching excellence as an expression of a hidden curriculum that is central to the cultural and structural etiology of the inequities clinical teachers experience in their pursuit of clinical teaching excellence. These elements include inequity in relation to time for participation in faculty development and recognition for clinical teaching excellence that exist within AMCs. To further compound these issues, AMCs often engage in the deployment of poor criteria and communication strategies concerning local standards of teaching excellence. Such inequities and poor governance can threaten the clinical teaching workforce's engagement, satisfaction and retention, and ultimately, can create negative downstream effects on the quality of patient care. While there are no clear normative solutions, we suggest that the examination of local policy documents, generation of stakeholder buy-in, and a culturally sensitive, localized needs assessment and integrated knowledge translation approach can develop a deeper understanding of the localized nature of this problem. The findings from local interrogations of structural, cultural and process problems can help to inform more tailored efforts to reform and improve the epistemic value of clinical teaching excellence. In conclusion, we outline a local needs assessment plan and research study that may serve as a conceptually generalizable foundation that could be applied to multiple institutional contexts.

Trust and risk pitfalls in medical education: A qualitative study of clinical teachers

PURPOSE

Learning opportunities in teaching hospitals are gated by clinical teachers. One way to unpack their decision-making is to employ a 'trust and risk' model. This study aimed to uncover clinical teachers' experience of trust, risk and vulnerability as they participate in medical education.

METHODS

Hospital-based clinical teachers were interviewed about trust, risk and vulnerability in medical education. Data analysis was undertaken using a constructivist, qualitative framework.

RESULTS

Twenty demographically diverse clinical teachers participated. Trust and risk were regarded as fundamental workplace and teaching concepts. Their concerns fell into three domains of risk: clinical, teaching and personal. Being trusted unlocked clinical learning opportunities, whereas trust failure limited future participation. Feeling trusted or not affected wellbeing and self-efficacy. Trust and risk pitfalls in education included bias, asymmetry and sidelining.

CONCLUSIONS

This study adds to the literature by voicing clinical teachers' personal risks and vulnerabilities. Attention was drawn to the benefits of being perceived as trustworthy, and to the clinical, teaching and personal vulnerabilities of trust failure.If expert judgement of trustworthiness is to be legitimised as meaningful assessment, clinical teachers must be aware not only of how trust is built, but also the pitfalls of trust failure.

The curious case of case study research

The conceptualisation of 'good' medical education research as hypothesis testing to identify universal truths that are generalisable across contexts has been challenged. Joining this conversation, the field of health professions education research is complex and contextual and there are ways of examining and reporting locally based activities and innovations, which can be of general value. This position leads to a focus on case study research (CSR), inquiry bound in time and place that generates thick descriptions and close interpretations to reach explanations. CSR has grown in sophistication in recent years and can inform practice and advance the science of medical and health professions education. The authors evaluated the current state of the science of CSR in the medical education literature by identifying and reviewing 160 papers. Most articles presented as 'case studies' were not in fact CSR. Moreover, most articles failed to go beyond a 'we did this' account. The authors explore definitions of CSR, and they examine dominant CSR methodologists, Yin, Stake and Merriam, and their respective approaches to CSR. They then set out some of the basic tenets of CSR (case definition, methods of data collection and analysis) and consider the logics of CSR (its structures, purposes, assumptions and symbols). CSR challenges are considered next (such as emic and etic perspectives; ethical complexities; generalisability; quality; and reporting and reflexivity). The authors conclude that context is a mechanism, which needs to be understood, and rigorous CSR provides the structures and criticality to do so, opening up new areas of understanding and inquiry.

Change is never easy: How management theories can help operationalise change in medical education

CONTEXT

Medical education is neither simple nor stable, and is highly contextualised. Hence, ways of perceiving multiple connections and complexity are fundamental when seeking to describe, understand and address concerns and questions related to change.

PROPOSAL

In response to calls in the literature, we introduce three examples of contemporary organisational theory which can be used to understand and operationalise change within medical education. These theories, institutional logics, paradox theory and complexity leadership theory, respectively, are relatively unknown in medical education. However, they provide a way of making sense of the complexity of change creatively. Specifically, they cross-cut different levels of analysis and allow us to 'zoom in' to micro levels, as well as to 'zoom out' and connect what is happening at the individual level (the micro level) to what happens at a wider institutional and even national or international level (the macro level), thereby providing a means of understanding the interactions among individuals, teams, organisations and systems. We highlight the potential value of these theories, provide a brief discussion of the few studies that have used them in medical education, and then briefly critique each theory.

CONCLUSIONS

We hope that by drawing the attention of readers to the potential of these management theories, we can unlock some of the complexity of change in medical education, support new ways of thinking and open new avenues for research.

When logics of learning conflict: an analysis of two workplace-based continuing education programs

Educators, practitioners, and policy makers are calling for stronger connections between continuing education (CE) for professionals and the concerns of workplaces where these professionals work. This call for greater alignment is not unique to the health professions. Researchers within the field of higher education have long wrestled with the complexities of aligning professional learning and workplace concerns. In this study, we extend this critical line of inquiry to explore the possible conceptual intersections between two CE programs acting within a single healthcare organization. Both programs are concerned with improving patient care, primarily by changing the ways professionals think and talk with one another. However, the two programs have different historical origins: one in a workplace, the other within a university setting. Introducing the concept of "modes of ordering" as a way to analyze the curricula, we argue the programs are operating through separate logics of learning. We label these two modes of ordering: (1) learning as standardization and (2) learning as identification. Through our discussion, we explore how these different modes demand different roles for educators and participants. Ultimately, we argue that both have value. However, we also argue that educators require conceptual tools to sensitize them to the possibility of competing logics of learning and the subsequent implications for their practice as educators. In conclusion, we offer the metaphor of CE educator as choreographer, connecting concepts and practices within these logics in productive ways while continually navigating the various learning imperatives acting on professionals at any given time.

Who owns responsibility? An administrator's take on implementing time-variable medical training in teaching hospitals

Introduction: Developments in outcome-based medical education led to the introduction of time-variable medical training (TVMT). Although this idea of training may be a consequence of competency-based training that calls for individualized learning, its implementation has posed significant challenges. As a new paradigm it is likely to have repercussions on the organization of teaching hospitals. The purpose of this study is therefore to explore how hospital administrators cope with this implementation process. Methods: We conducted an exploratory qualitative study for which we interviewed administrators of hospitals who were actively implementing TVMT in their postgraduate programs. Results: Several problems of implementation were identified: existing governance structures proved unfit to cope with the financial and organizational implications of TVMT. Administrators responded to these problems by delegating responsibilities to departments, reallocating tasks, learning from other hospitals and scaling up their teaching facilities. Conclusions: Hospital administrators perceived the implementation of TVMT as challenging. TVMT affects the existing equilibrium between education and clinical service. Administrators' initial attempts to regain control, using steering strategies that were based on known concepts and general outcomes, including cutting departmental budgets did not work, nor did their subsequent wait-and-see approach of leaving the implementation to the individual departments.

Facilitators and barriers to teaching undergraduate medical students in general practice

CONTEXT

Globally, primary health care is facing workforce shortages. Longer and higher-quality placements in primary care increase the likelihood of medical students choosing this specialty. However, the recruitment and retention of community primary care teachers are challenging. Relevant research was predominantly carried out in the 1990s. We seek to understand contemporary facilitators and barriers to general practitioner (GP) engagement with undergraduate education. Communities of practice (CoP) theory offers a novel conceptualisation, which may be pertinent in other community-based teaching settings.

METHODS

Semi-structured interviews were undertaken with 24 GP teachers at four UK medical schools. We purposively sampled GPs new to teaching, established GP teachers and GPs who had recently stopped teaching. We undertook NVivo-assisted deductive and inductive thematic analysis of transcripts. We used CoP theory to interpret data.

RESULTS

Communities of practice theory illustrated that teachers negotiate membership of three CoPs: (i) clinical practice; (ii) the medical school, and (iii) teaching. The delivery of clinical care and teaching may be integrated or exist in tension. This can depend upon the positioning of the teaching and teacher as central or peripheral to the clinical CoP. Remuneration, workload, space and the expansion of GP trainee numbers impact on this. Teachers did not identify strongly as members of the medical school or a teaching community. Perceptions of membership were affected by medical school communication and support. The findings demonstrate gaps in medical school recruitment.

CONCLUSIONS

This research demonstrates the marginalisation of primary care-based teaching and proposes a novel explanation rooted in CoP theory. Concepts including identity and membership may be pertinent to other community-based teaching settings. We recommend that medical schools review and broaden recruitment methods. Teacher retention may be improved by optimising the interface between medical schools and teachers, fostering a teaching community, increasing professional rewards for teaching involvement and altering medical school expectations of learning in primary care.

Uncovering Cultural Barriers to Quality Improvement Learning in a Trauma Program: An Ethnographic Study

OBJECTIVE

Quality improvement (QI) training is an essential component of postgraduate surgical education and can occur through formal and informal education programs. Informal QI education requires that faculty take advantage of learning opportunities in the hospital setting. Trauma rotations appear ideal opportunities for informal QI learning given that performance improvement is a mandatory component of care at verified trauma centers. It is unclear, however, whether QI initiatives within trauma programs are well integrated into trainee education. This study explored the QI learning environment in a level 1 academic trauma center.

STUDY DESIGN

An ethnographic study using observation and interviews methods. The theoretical lens of hidden curriculum was used to interpret the data and generate hypotheses around faculty and trainee experiences.

SETTING

University of Toronto and Sunnybrook Health Sciences Center.

PARTICIPANTS

Twenty-seven observations involving more than 50 faculty and trainees; seventeen interviews with faculty and surgical trainees.

RESULTS

All faculty and trainees endorsed QI and informal QI learning. Discrepant experiences were found regarding opportunities to learn and do QI in the clinical setting. Faculty viewed themselves as perpetually doing and teaching QI while trainees perceived little to no QI learning. Trainees identified Morbidity and Mortality rounds as the main opportunity for QI learning; however, traditional teaching style through "pimping" and a largely clinical focus acted as barriers to QI education. Furthermore, trainees chiefly viewed QI as service to the institution, rather than as a form of learning, which contributed to their disinterest in taking up informal QI lessons.

CONCLUSION

Informal QI education is highly valued and desired in academic trauma centers but enduring teaching methods, inconsistencies in the cultural learning environment and a hidden curriculum devaluing QI learning are persistent barriers to change.

The Association Between Residency Learning Climate and Inpatient Care Experience in Clinical Teaching Departments in the Netherlands

PURPOSE

To examine the association between residency learning climate and inpatient care experience.

METHOD

The authors analyzed 1,201 evaluations of the residency learning climate (using the Dutch Residency Educational Climate Test questionnaire) and 6,689 evaluations of inpatient care experience (using the Consumer Quality Index Inpatient Hospital Care questionnaire) from 86 departments across 15 specialties in 18 hospitals in the Netherlands between 2013 and 2014. The authors used linear hierarchical panel analyses to study the associations between departments' overall and subscale learning climate scores and inpatient care experience global ratings and subscale scores, controlling for respondent- and department-level characteristics and correcting for multiple testing.

RESULTS

Overall learning climate was not associated with global department ratings (b = 0.03; 95% confidence interval -0.17 to 0.23) but was positively associated with specific inpatient care experience domains, including communication with doctors (b = 0.11; 0.02 to 0.20) and feeling of safety (b = 0.09; 0.01 to 0.17). Coaching and assessment was positively associated with communication with doctors (b = 0.22; 0.08 to 0.37) and explanation of treatment (b = 0.22; 0.08 to 0.36). Formal education was negatively associated with pain management (b = -0.16; -0.26 to -0.05), while peer collaboration was positively associated with pain management (b = 0.14; 0.03 to 0.24).

CONCLUSIONS

Optimizing the clinical learning environment is an important step toward ensuring high-quality residency training and patient care. These findings could help clinical teaching departments address those aspects of the learning environment that directly affect patient care.

Education and service: how theories can help in understanding tensions

OBJECTIVES

This paper reviews why tensions between service and education persist and highlights that this is an area of medical education research (MER) that, to date, lacks a robust body of theory-driven research. After carrying out a review of the literature on service-education tensions in medical education and training, we turn to consider how theory can help provide new insights into service-education tensions.

METHODS

We conducted a search of the literature on service-education tensions since 1998 to examine the use of theory in studies on this topic.

RESULTS

We identified 44 out of 603 relevant papers. Their focus fell into four broad categories: time residents spent on 'service' and 'education'; perceptions of the balance between service and education; considerations of how best to define service and education, and the impact of structural and systems changes on education/training. Of the papers reporting primary research, the dominant methodology was the bespoke survey. Rarely were the precise natures of tensions or how different factors interact to cause tensions examined in detail.

DISCUSSION

Through discussion and reflection, we then agreed on the applicability of four sociocultural theories for illuminating some examples of service-education tensions. We present four sociocultural theories: Holland's figured worlds, Kemmis et al.'s practice architectures, Lave and Wenger's situated learning and Engeström's cultural-historical activity theory (CHAT or AT). We describe each and then briefly illustrate how each theory can support new ways of thinking and potential directions for research focusing on education-service tensions.

CONCLUSIONS

The use of theory in research studies will not resolve service-education tensions. However, what theory can do is illuminate and magnify different aspects of service-education tensions, to generate new insight and knowledge that can then be used to inform future research and changes in practice.

Beyond hands-on and hands-off: supervisory approaches and entrustment on the inpatient ward

CONTEXT

The concept of entrustment has garnered significant attention in medical specialties, despite variability in supervision styles and entrustment decisions. There is a need to further study the enactment of supervision on inpatient wards to inform competency-based assessment design.

METHODS

Attending physicians, while supervising on clinical teaching inpatient wards, were invited to describe a recent moment of enacting supervision with an internal medicine resident. Constructivist grounded theory guided data collection and analysis. Interview transcripts were analysed in iterative cycles to inform data collection. Constant comparison was used to build a theory of supervision from the identified themes.

RESULTS

In 2016-2017, 23 supervisors from two Canadian universities with supervision reputations ranging from very involved to less involved participated in one or two interviews (total: 28). Supervisors were not easily dichotomised into styles based on behaviour because all used similar oversight strategies. Supervisors described adjusting between 'hands-on' (e.g. detail oriented) and 'hands-off' (e.g. less visible on ward) styles depending on the context. All also contended with the competing roles of clinical teacher and care provider. Supervisors made a distinction between the terms `entrust' and `trust', and did not grant complete entrustment to senior residents.

CONCLUSIONS

We propose that a supervisor's perceived responsibility for the ward underlies adjustments between 'hands-on' (i.e. personal ward responsibility) and 'hands-off' (i.e. shared ward responsibility) styles. Our approaches to clinical supervision model combines this responsibility tension with the tension between patient care and teaching to illustrate four supervisory approaches, each with unique priorities influencing entrustment. Given the fluidity in supervision, documenting changes in oversight strategies, rather than absolute levels of entrustment, may be more informative for assessment purposes. Research is needed to determine if there is sufficient association between the supervision provided, the entrustment decision made and the supervisor's trust in a trainee to use these as proxies in assessing a trainee's competence.

Does perceived organisational support influence career intentions? The qualitative stories shared by UK early career doctors

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 semistructured interviews incorporating a narrative inquiry approach for data collection. Interview questions were informed by the literature as well as 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 Support (POS) to group themes and aid conceptual generalisability.

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 satisfaction and engagement. Positive relationships with senior staff and colleagues seemed to act as 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 organisation and its representatives (supervisors and colleagues) had a detrimental impact on participants' intentions to stay working within the National Health Service (NHS).

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.