Social-cognitive models such as the theory of planned behavior have demonstrated efficacy in predicting behavior, but few studies have examined the theory as a predictor of treatment adherence in chronic illness. We tested the efficacy of the theory for predicting adherence to treatment in chronic illness across multiple studies. A database search identified 27 studies, meeting inclusion criteria. Averaged intercorrelations among theory variables were computed corrected for sampling error using random-effects meta-analysis. Path-analysis using the meta-analytically derived correlations was used to test theory hypotheses and effects of moderators. The theory explained 33 and 9 % of the variance in intention and adherence behavior respectively. Theoretically consistent patterns of effects among the attitude, subjective norm, perceived behavioral control, intention and behavior constructs were found with small-to-medium effect sizes. Effect sizes were invariant across behavior and measurement type. Although results support theory predictions, effect sizes were small, particularly for the intention-behavior relationship.

ObjectivesExplore trainee doctors’ experiences of postgraduate training and perceptions of fairness in relation to ethnicity and country of primary medical qualification.DesignQualitative semistructured focus group and interview study.SettingPostgraduate training in England (London, Yorkshire and Humber, Kent Surrey and Sussex) and Wales.Participants137 participants (96 trainees, 41 trainers) were purposively sampled from a framework comprising: doctors from all stages of training in general practice, medicine, obstetrics and gynaecology, psychiatry, radiology, surgery or foundation, in 4 geographical areas, from white and black and minority ethnic (BME) backgrounds, who qualified in the UK and abroad.ResultsMost trainees described difficult experiences, but BME UK graduates (UKGs) and international medical graduates (IMGs) could face additional difficulties that affected their learning and performance. Relationships with senior doctors were crucial to learning but bias was perceived to make these relationships more problematic for BME UKGs and IMGs. IMGs also had to deal with cultural differences and lack of trust from seniors, often looking to IMG peers for support instead. Workplace-based assessment and recruitment were considered vulnerable to bias whereas examinations were typically considered more rigorous. In a system where success in recruitment and assessments determines where in the country you can get a job, and where work–life balance is often poor, UK BME and international graduates in our sample were more likely to face separation from family and support outside of work, and reported more stress, anxiety or burnout that hindered their learning and performance. A culture in which difficulties are a sign of weakness made seeking support and additional training stigmatising.ConclusionsBME UKGs and IMGs can face additional difficulties in training which may impede learning and performance. Non-stigmatising interventions should focus on trainee–trainer relationships at work and organisational changes to improve trainees’ ability to seek social support outside work.

ObjectivesInvestigate the work–life balance of doctors in training in the UK from the perspectives of trainers and trainees.DesignQualitative semistructured focus groups and interviews with trainees and trainers.SettingPostgraduate medical training in London, Yorkshire and Humber, Kent, Surrey and Sussex, and Wales during the junior doctor contract dispute at the end of 2015. Part of a larger General Medical Council study about the fairness of postgraduate medical training.Participants96 trainees and 41 trainers. Trainees comprised UK graduates and International Medical Graduates, across all stages of training in 6 specialties (General Practice, Medicine, Obstetrics and Gynaecology, Psychiatry, Radiology, Surgery) and Foundation.ResultsPostgraduate training was characterised by work–life imbalance. Long hours at work were typically supplemented with revision and completion of the e-portfolio. Trainees regularly moved workplaces which could disrupt their personal lives and sometimes led to separation from friends and family. This made it challenging to cope with personal pressures, the stresses of which could then impinge on learning and training, while also leaving trainees with a lack of social support outside work to buffer against the considerable stresses of training. Low morale and harm to well-being resulted in some trainees feeling dehumanised. Work–life imbalance was particularly severe for those with children and especially women who faced a lack of less-than-full-time positions and discriminatory attitudes. Female trainees frequently talked about having to choose a specialty they felt was more conducive to a work–life balance such as General Practice. The proposed junior doctor contract was felt to exacerbate existing problems.ConclusionsA lack of work–life balance in postgraduate medical training negatively impacted on trainees' learning and well-being. Women with children were particularly affected, suggesting this group would benefit the greatest from changes to improve the work–life balance of trainees.

Objective To investigate trainee doctors’ and trainers’ perceptions of the validity of the Annual Review of Competence Progression (ARCP) using Messick’s conceptualisation of construct validity. Design Qualitative semi-structured focus groups and interviews with trainees and trainers. Setting Postgraduate medical training in London, Kent Surrey and Sussex, Yorkshire and Humber, and Wales in November/December 2015. Part of a larger study about the fairness of postgraduate medical training. Participants Ninety-six trainees and 41 trainers, comprising UK and international medical graduates from Foundation, General Practice, Medicine, Obstetrics and Gynaecology, Psychiatry, Radiology, and Surgery, at all levels of training. Main outcome measures Trainee and trainer perceptions of the validity of the ARCP as an assessment tool. Results Participants recognised the need for assessment, but were generally dissatisfied with ARCPs, especially UK graduate trainees. Participants criticised the perceived tick-box nature of ARCPs as measuring clerical rather than clinical ability, and which they found detrimental to learning. Trainees described being able to populate their e-portfolios with just positive feedback; they also experienced difficulty getting assessments signed off by supervisors. ARCPs were perceived as poor at identifying struggling trainees and/or as discouraging excellence by focussing on minimal competency. Positive experiences of ARCPs arose when trainees could discuss their progress with interested supervisors. Conclusions Trainee and trainer criticisms of ARCPs can be conceptualised as evidence that ARCPs lack validity as an assessment tool. Ongoing reforms to workplace-based assessments could address negative perceptions of the ‘tick-box’ elements, encourage constructive input from seniors and allow trainees to demonstrate excellence as well as minimal competency, while keeping patients safe.

Objectives To investigate doctors’ intentions to raise a patient safety concern by applying the socio-psychological model ‘Theory of Planned Behaviour’. Design Qualitative semi-structured focus groups and interviews. Setting Training venues across England (North West, South East and South West). Participants Sampling was purposeful to include doctors from differing backgrounds and grades. Main outcome measures Perceptions of raising a patient safety concern. Results While raising a concern was considered an appropriate professional behaviour, there were multiple barriers to raising a concern, which could be explained by the Theory of Planned Behaviour. Negative attitudes operated due to a fear of the consequences, such as becoming professionally isolated. Disapproval for raising a concern was encountered at an interpersonal and organisational level. Organisational constraints of workload and culture significantly undermined the raising of a concern. Responses about concerns were often side-lined or not taken seriously, leading to demotivation to report. This was reinforced by high-profile cases in the media and the negative treatment of whistle-blowers. While regulator guidance acted as an enabler to justify raising a concern, doctors felt disempowered to raise a concern about people in positions of greater power, and ceased to report concerns due to a perceived lack of action about concerns raised previously. Conclusions Intentions to raise a concern were complex and highly contextual. The Theory of Planned Behaviour is a useful model to aid understanding of the factors which influence the decision to raise a concern. Results point to implications for policymakers, including the need to publicise positive stories of whistle-blowers and providing greater support to doctors.