Scratching beneath the surface: How organisational culture influences curricular reform

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)?


| INTRODUCTION
Curricular reform is often proposed as the means to address issues with medical education and training. However, previous studies have suggested that curricular reform, even with the best of intentions, may not lead to noticeable change. [1][2][3][4] Indeed, Whitehead and colleagues 1 use the metaphor of a carousel to illustrate that the returning themes of curricular reform circle around repeatedly. Getting off this carousel fundamentally requires changing from one way of doing things to another.
As with most organisational change, curriculum reform tends to be driven by leaders who propose to change the vision, structure or procedures of a curriculum and then persuade others to implement their recommendations. [5][6][7][8] However, such top-down change efforts often fail to meet their intended purposes and instead result in disturbance, resistance to change from individuals and groups, and unintended consequences. [9][10][11] This is no different in medical education, where attempts to reform curricula have been previously described as challenging and disruptive. 12 Reforming a curriculum involves changing organisational processes, systems and structures, none of which is easy to change. However, even more challenging is changing culture: the management literature is clear that organisational culture-'the taken-for-granted assumptions and behaviours of an organisation's members' 13 (p171) -is a significant, indeed the greatest barrier, to change implementation. [14][15][16] That organisational culture influences change processes has been demonstrated in business, 17,18 higher education, 19 and healthcare and medical education. [20][21][22][23][24][25][26] In short, to understand curriculum reform requires an understanding of organisational culture. However, although empirical studies evaluating change/curricular reform in medical education often invoke culture to explain their observations, [27][28][29] these studies have been criticised for insufficiently acknowledging faculty traditions and values. 9 Others suggest that medical education scholars have overlooked theory-informed approaches to demystify the word 'culture'. 28 A gap in the medical education literature thus exists for the use of theorydriven approaches to understand how organisational culture shapes change. 30 This understanding is necessary to ensure aspects of culture, which may limit change are identified and addressed. 31,32 The roll out of a curricular reform of early-years surgical training in the UK (called 'Improving Surgical Training (IST)') 33 was a natural opportunity to examine cultural barriers to, and enablers of change implementation in surgical education and training. IST had met with success at national level according to crude outcome measures as examination pass rates, intention to continue training in surgery and fill rates of onward programmes. 34,35 However, evaluation data showed variations in implementation between hospitals, and in trainees' and trainers' perceptions of the success of IST. Given these variations, and previous findings that deep-seated values and practices can exert powerful resistance to external influence in surgery, [36][37][38][39] we considered that the influence of culture on change was worthy of consideration. Thus, our specific research question was: in what ways did organisational culture influence the implementation of IST throughout Scotland? 2 | METHODS We adopted a qualitative approach given our interest was understanding rather than measuring. 40 Our study was underpinned by social constructivism, acknowledging that reality is socially constructed and thus culture and context are important in the process of knowledge construction and accumulation. 41 We used individual interviews to explore participants' experiences of a curricular reform, including their views of cultural barriers to, and enablers of reform.

| Context
Our context was UK surgical training (residency), specifically the first 2 years of postgraduate surgical training, which follows the 2-year generic Foundation Programme, which in turn follows medical school.
This initial stage of surgical training, known as Core Surgical Training (CST), aims to give trainees a broad exposure across different surgical specialties.
In 2013 the Shape of Training report recommended changes to postgraduate medical education to address problems including the imbalance between service provision and training, the lack of time for training and the lack of flexibility during the training process. [42][43][44] These problems were particularly notable in CST. Core surgical trainees (usually referred to as CT1 or CT2s, equivalent to residency years 1 and 2) had long reported dissatisfaction with their education and training experiences [45][46][47][48] because of shift working and heavy clinical service workloads, which limited surgical experience, 43,49,50 and led to a lower sense of 'belonging' within teams and relatively poor relationships with their trainers. 51,52 'Improving Surgical Training (IST)' was proposed to redress these tensions and to improve the quality of training experience. 33 IST's recommendations focused on reducing trainees' service commitments and increasing the time dedicated to training during the working week, enabling Consultant Surgeons with educational/clinical supervision roles (henceforth trainers) to dedicate more time to deliver training, increasing the length of rotations to enhance trainee-trainer relationships, more focused training opportunities (e.g. simulation) and involving health professionals within the wider surgical team to deliver patient care thereby freeing trainees to seek training.
Our specific context was Scotland, UK, where IST was implemented across all CST posts from August 2018. Compared with the other UK sites, in Scotland particular priority had been put on resourcing Educational Supervisors' additional time, and on providing an extensive programme of simulation-based training throughout CST. 53

| Participants
There is an annual intake of 45-55 core surgical trainees (CTs) across Scotland, assigned into two programmes, East and West of Scotland, each of which is led by a Training Programme Director. CST is delivered across 14 territorial Health Boards, in a wide variety of hospital settings: regional tertiary units, district general hospitals and rural hospitals. The programmes consist of 4-to-6-month rotations and during every rotation each trainee is assigned one educational supervisor and several nominated clinical supervisors.
On receiving project approval and appropriate institutional consents (see later), CTs and trainers from across Scotland were invited to participate in the study. The two Training Programme Directors emailed invitations to prospective participants on our behalf, between April to August 2020 (trainees and trainers) and February to May 2021 (trainers only). We also asked members of the research team and participants for assistance in identifying potential participants (snowball sampling 54 ). Two email reminders about the study were sent during both participant recruitment rounds. Interested participants were asked to contact the main researcher directly by email and were then provided with more information about the study.

| Data collection
We developed a semi-structured interview schedule 55  The interview schedule ensured consistency, but interviews were iterative and continued until the participant felt that they had shared their experiences sufficiently. Open questions guided discussion as far as possible, supplemented by probes where required. Data were collected during the Covid-19 pandemic and so interviews were conducted virtually by AS using the Microsoft Teams platform.

| Data analysis
Interviews were digitally audio-recorded for later transcription. Participants were anonymised during the transcription process. Transcripts were entered into the qualitative data analysis software NVivo v12.0 (QRS International Pty Ltd, Doncaster, Victoria, Australia) to facilitate data management and coding. We initially conducted a thematic analysis to identify themes and sub-themes. 56 After team discussions of preliminary codes and resolution of any coding disagreements, coding occurred iteratively and inductively, focusing throughout on the research question. After this, following further team discussion and drawing on JC's knowledge of management theories and literature, we extended beyond simple thematic analysis to critically analyse organisational culture using Johnson's cultural web theory. 13 This model offered a visual approach to expose the manifestations of organisational culture and how these might have influenced the implementation of IST. [57][58][59][60][61] Johnson's cultural web model is built on three premises. First, that organisational culture is 'the taken-for-granted assumptions and behaviours of an organisation's members'. 13(p171) This 'taken-forgrantedness' makes articulating organisational culture difficult, and the cultural web model helps elucidate and visualise the culture of an organisation. 62 The second premise is that the six elements, or artefacts, of the cultural web model-routines and rituals, stories, symbols, power structures, control systems and organisational structures-and how they relate, need to be understood to comprehend the central cultural paradigm (see Fig. 1). It is noteworthy that the paradigm in the cultural web theory refers to the 'big picture' of the assumptions that are not necessarily explicit and not considered problematic and thus is very different from the meaning of paradigm in scientific research. The third premise is how individuals or groups experienced historic events such as change within an organisation, plays a key role in determining current behaviours and future strategies. For example, events such as mergers and acquisitions or devolutions impact current beliefs and behaviours, which in turn determine responses to future environmental changes.

| Reflexivity
Qualitative research is dependent on the relationship between the researcher and the research process. 41,63 We considered our positions and relationships with the data continually and critically in view of our different inter-disciplinary backgrounds (psychology, pharmacology, nursing and surgery), different levels of knowledge and experience of delivering and managing surgical education, training and research. For example, as a surgical trainee from another UK country who took time out of training to do a PhD, AS was both an insider and an outsider; external to Scotland's healthcare system but an insider by being a surgical trainee with knowledge of training within the NHS.

| Ethics
The host University's Research Governance team and the host NHS provider's Quality Improvement and Assurance Team classified this study as a National Evaluation Audit (project number 4945), thus exempting it from ethical approval. However, we followed core ethical principles: obtaining written, informed consent from potential research participants that their (anonymised) responses could be used for research purposes, that participation was voluntary and that participants had the right to withdraw at any time.

| RESULTS
Forty-six trainees and 25 trainers responded to the email invitations. Table 1   Similarly, with elective duties, the routine in some places dictated that CTs complete the ward round prior to attending their allocated activity: '… you might have been scheduled to be in an elective operating list but then the ward round needed done …' (CT27).
In response to IST recommendations (e.g. maximisation of training time during daytime hours), some departments changed their ways of working, either adapting existing rotas to maximise training opportunities or introducing supernumerary roles. An example of the first of these was dividing the emergency rota into two so that CTs could either be responsible for acute surgical admissions (developing clinical skills) or for the emergency theatre (thus learning operative skills). The creation of supernumerary roles freed trainees from service, and empowered them to seek training opportunities more freely: '… there was some structure to the week in that I was assigned which theatre or clinic to go to … but because I was supernumerary, I had that luxury from the department to kind of design my own and achieve my own goals' (CT26).
Training experiences between departments that adopted new rotas contrasted with those where rotas remained unchanged: Where rotas remain unchanged despite IST, 'it didn't seem that anything was truly translating to IST in the switch from core training.
It just seemed to be the same' (CT07). In short, it seemed that rotas could either support or block IST-related change, depending on the specific context. Historical attitudes towards core trainees were slow to change:

| Stories
'historically the people that are core trainees, we're the ward monkeys, and that's what we're seen as …' (CT03).

| Symbols
This element relates to words, objects, conditions and acts that have meaning in ways that influence organisational beliefs and values, and relationships within organisations.
One obvious symbol was the acts associated with training. Often, the first symbol was the act of induction to the workplace at the start of the rotation: whether this was formal, informal, planned or ad hoc, welcoming or not. For example, some trainers made contact with their trainee prior to their arrival, an act that was welcomed by trainees: 'it feels like you're starting the induction process early and you can start sharing information' (TR20).
The next symbol was an object, specifically the regular documentation required within the trainee's e-portfolio of their progress against the learning agreement and curricular competencies. Although one of the aims of IST was more frequent reviews of progression within the trainee-trainer dyad, the pressures of service delivery on trainers impacted on the quality of observation/supervision and feedback: 'Most of the consultants were quite happy just to fill out anything. Some consultants put more effort in and said, "Ok, these are the things you should go and read". Others were just happy to say, "that was good.

| Power structures
Power structure refers to the groups or individuals with the most influence, who determine the actions and behaviours expected of those with less power and who may be expected to be most closely aligned with the core assumptions of the organisational culture. 64

| Organisational structures
Organisational structure refers to formal structures, roles and relationships, which reflect power relationships between people who carry out different roles (i.e. lines of accountability and responsibility). 64 The potential for change was influenced by relationships between hospital management and surgical trainers.

| DISCUSSION
We used Johnson's cultural web 13 as an analytical framework to evaluate the implementation of a national curricular reform of surgical education and training, which evaluation data suggested had been experienced differently in different places.
In terms of our specific research question, identifying the ways in which organisational culture influenced the implementation of Improving Surgical Training (IST) in Scotland, we found that where there was no or minimal change in routines, structures and systems (e.g. where there were no changes to consultants' job plans to free up time for training), then nothing really changed, and the historical context prevailed. Where changes in these cultural elements did occursometimes because trainers used IST as a negotiation tool within their hospital-there was some evidence of change. There was a sense that IST recommendations were more readily embraced in smaller surgical departments. These seemed to have more of a culture of interactions and connections than larger units, which likely to contribute to more effective change. 67 We found that trainers' current and past experiences of supervi- trainers and allied health professionals (stories and symbols). Tensions between trainers and managers were also described in our data (control systems).
We tentatively suggest that several forces may explain the argu- All data collection approaches have strengths and weaknesses. 55 During the pandemic, virtual interviews were the only way to obtain responses from trainers and trainees across many different contexts.
We encountered difficulty with recruiting trainers initially, hence our second round of invitations to take part in the study. We believe this was due to the COVID-19 pandemic, so we waited until after (what was) the second wave of the pandemic before sending out second invitations to trainers only.
Recruiting managers as participants would have afforded their perspective on enacting curricular reforms within their organisation.
However, healthcare managers, other than Directors of Medical Education, were not involved in the IST proposal discussions and implementation stages of the curricular reform (This, of course, may have contributed to the issues reported, as discussed earlier).
As with any voluntary study, there would have been an element of participant self-selection. However, as eventually we saw the same ideas coming up repeated and no new themes (thematic saturation or data sufficiency 85 ), we stopped data collection and feel confident that our data reflects common experiences.
The initial inductive data analysis indicated the importance of culture so we read the management literature widely and considered many different theories before settling on cultural web theory because, in our view and as a descriptive model of change (rather than a processual one 86  Seen through the lens of Johnson's cultural web, our data illuminate the workings of a curricular reform that met with varying degrees of success across different hospital sites. This reinforces that curricular reform is not simply about putting recommendations into practice.
Context must be taken into account when planning and evaluating change.