Scotland's Improving Surgical Training (IST) pilot: a tale of two cultural webs

Adarsh Shah, Kim Walker, Lorraine Hawick, Kenneth Walker, Jennifer Cleland

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“Improving Surgical Training” (IST) was proposed as a means to rebalance tensions between service and training, the loss of the surgical “firm”, and the trainee-trainer relationship due to duty hour regulations and the move to shift working. As with any curricular reform, understanding the context and mechanisms of change linked to introducing IST is critical.

This qualitative study aimed to explore trainee, trainer, and key stakeholder views of IST in Scotland, a context where IST was implemented on a nationwide basis. We were particularly interested in exploring perceptions of organisational and departmental support for IST as these are known to underpin successful change.

Interviews were carried out with core surgical trainees (n=46) and trainers (n=25) across Scotland, and UK-wide stakeholders (n=16) involved in IST. After transcription, initial analysis was inductive (data-driven). This analysis indicated many explicit and implicit issues/factors which seemed to be acting as barriers or facilitators to the implementation of IST. To illuminate these further, we carried out a secondary analysis using Johnson’s cultural web (Johnson, 1988) which organised the data into six inter-related elements described below.

The values and beliefs at the core of the cultural web e.g., the importance of IST recommendations (daytime training, enhanced supervision) were widely held. However, the data indicated that how IST was enacted was different across localities. How this played out related to Organisational Structures (e.g., geographical set-up), Symbols (e.g., rota design and structures), Power Structures (e.g., relationships with hospital management), the Control System (e.g., consultant job plans), Rituals and Routines (e.g., feedback cultures) and Stories (e.g., historical [local] training culture).

Quality of patient care and patient outcomes are the product of service delivery and training. Making explicit the elements of organisational culture(s) that pervade efforts to implement IST can help inform future change.
Original languageEnglish
Publication statusPublished - 31 May 2022
EventInternational Conference on Surgical Education and Training (ICOSET) 2022 - The Royal College of Surgeons of Edinburgh, Edinburgh, United Kingdom
Duration: 31 May 20221 Jun 2022


ConferenceInternational Conference on Surgical Education and Training (ICOSET) 2022
Abbreviated titleICOSET 22
Country/TerritoryUnited Kingdom


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