Scotland's improving surgical training (IST) pilot: a tale of two cultural webs

‘Improving surgical training’ (IST) was proposed to rebalance tensions between service and training, loss of the surgical ‘firm’ and trainee–trainer relationships 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 explored trainee, trainer and key stakeholder views of IST in Scotland, a context where IST implementation occurred nationally. We were particularly interested in exploring perceptions of organisational and departmental support for IST as these drive 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, the initial inductive (data-driven) analysis indicated many explicit and implicit issues/factors acting as barriers or facilitators to IST implementation. To illuminate these further, we carried out a secondary analysis using Johnson's cultural web1 which organised the data into six inter-related elements. Values and beliefs at the core of the cultural web, for example, the importance of IST recommendations (daytime training, enhanced supervision), were widely held. However, data indicated that IST was enacted variably across localities. How this played out is related to organisational structures (e.g. geographical set-up), symbols (e.g. rota design), 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). Making explicit the elements of organisational culture(s) that pervade efforts to implement curricular reform can help strategise future change.