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Abstract
Objectives Irish healthcare has struggled with attrition and emigration. Reasons include long working hours and work–life balance. Worldwide interest in less-than-full-time (LTFT) postgraduate medical training is increasing. Potential benefits include cost savings, reduced burn-out and improved patient safety; potential difficulties include maintaining service provision and negative perceptions from colleagues. This study aimed to examine experiences, awareness and attitudes towards LTFT training in Ireland, to identify potential improvements.
Design This prospective qualitative study used semistructured interviews. Interview participants were selected by volunteering in response to advertisements and by purposeful sampling. Data were coded and compiled into key themes, with the sample size determined by code saturation.
Setting This study took place across a number of rural and urban centres in Ireland, including secondary and tertiary hospitals, administrative departments and postgraduate training offices.
Participants 29 participants were interviewed. Recruitment targeted doctors of varying levels and specialties (both in training and non-training posts), medical educators and other individuals involved in postgraduate medical training, such as training administrators and medical manpower managers.
Primary outcome measures Primary outcome measures include awareness of LTFT training in Ireland, satisfaction with it and its effectiveness in supporting career, service provision and training requirements.
Results Awareness of LTFT training was poor. Training structures were seen as inflexible. Trainees preferred higher whole-time-equivalent (WTE) hours, such as 70%–80% WTE, which may present administrative challenges. Participants felt LTFT training would have little impact on service provision. Some feared that LTFT training might affect career progression and competency, but participants with experience of LTFT training disagreed. Many felt that making LTFT training mainstream would foster positive attitudes.
Conclusions Potential improvements to LTFT training include increasing administrative and medical staff support, accommodating higher WTE percentages and providing liaison officers. Focused improvement of LTFT training could contribute to the welfare of doctors in postgraduate training.
- Burnout
- Human resource management
- Health Workforce
- Job Satisfaction
- MEDICAL EDUCATION & TRAINING
- QUALITATIVE RESEARCH
Data availability statement
No data are available. To protect privacy of individual participants, the unedited interview transcripts are not publicly available. Anonymised data from the transcripts are available via the corresponding author on reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Burnout
- Human resource management
- Health Workforce
- Job Satisfaction
- MEDICAL EDUCATION & TRAINING
- QUALITATIVE RESEARCH
STRENGTHS AND LIMITATIONS OF THIS STUDY
The qualitative nature of this study allows deeper understanding of challenges facing participants affected by less-than-full-time training, providing insights that can inform policy and practice in medical training in Ireland.
A diverse cohort of stakeholders was selected from multiple backgrounds, which allows a variety of perspectives to be identified, including medical, governance and management.
The ethics approval for this study placed limitations on direct recruitment of non-consultant hospital doctors on formal training programmes, so as to avoid any potential sense of coercion, allowing only indirect recruitment through advertisements.
The total number of interviewees was 29, which may have affected the frequency of certain themes identified, but as thematic saturation was achieved, it was unlikely that significant new codes would have been identified by additional interviews.
Background
Postgraduate medical specialty training is characterised internationally by several years of onerous working hours and academic requirements. In Ireland, a doctor’s career path normally commences with attaining a primary medical qualification (PMQ) of 4–6 years in duration, completed in a university setting with clinical placements. Further postgraduate training is then completed through working and learning in an apprenticeship model while fulfilling specific curricular and academic requirements, beginning with a 1-year internship. Non-consultant hospital doctors (NCHDs) wishing to become specialists—either a general practitioner or (for hospital-based specialties) a consultant—will then complete a minimum of 4–8 years working in specific training posts, organised and regulated by the Irish Medical Council, National Doctors Training and Planning (NDTP) and the individual postgraduate training bodies (PGTBs) for each specialty.1
International experience suggests increasing demand for less-than-full-time (LTFT) training.2 Benefits include cost savings from reduced overtime, enhanced staff retention, reduced burn-out, greater rostering flexibility, improved work–life balance and enhanced patient safety.3 4 The ‘triple aim’ has gained traction as a paradigm designed to optimise healthcare performance by improving patient experience, promoting population health and enhancing health system performance. This has been expanded in recent years to a ‘quadruple aim’ by adding improved healthcare staff well-being as a fourth goal required to help make the other three achievable.5 Actively encouraging LTFT training may prevent attrition and promote a sustainable workforce.6 Several difficulties have been cited in facilitating it, including rostering, negative perceptions by colleagues and reduced quality of training.3 7
Postgraduate medical trainees choose LTFT training for a variety of reasons, including caring responsibilities, physical and mental health, and the ability to pursue other opportunities. Published literature on LTFT training in the UK is best established in the specialities of anaesthesiology and surgery, but worldwide, LTFT training is most common in general practice (GP), with 33% of UK GP trainees being on LTFT programmes.8–10
There are increasing numbers of female doctors in the UK, with a rise of 38% between 2001 and 2012.11 Women are more likely to train LTFT than men.8 12 13 A 2014 survey of UK postgraduate doctors in training reported that 11% trained LTFT, with 80% of these being female; by contrast, 55% of the overall trainee workforce (both full-time and LTFT) was female.13 A 2018 study by the three royal colleges of physicians of the UK found that 15% of all trainees and 23% of consultants worked LTFT, representing a 5% increase over the previous 2 years. The same study also reported that 91% of LTFT trainees were female, meaning that a quarter of all female trainees worked LTFT, while only 3% of male trainees did so.14 Over a full working career, the Royal College of Physicians of London has stated that female doctors provide on average 60% of the labour of a single whole-time equivalent (WTE), compared with 80% for male doctors.12
The proportions of male doctors, and doctors with fewer children, looking to pursue LTFT training have increased disproportionately compared with female doctors and doctors with more children. This may be due to doctors placing greater importance on work–life balance than in the past, although the driving factors have not been investigated deeply in the literature.15
Child-rearing and household responsibilities are consistently cited as the most common reasons to pursue LTFT training.8 16–20 One 2016 UK study found that 88% of women and 65% of men in LTFT training had children.8 The same study reported that women living with a spouse were more likely to work LTFT, while men living with a spouse were less likely; the authors proposed that this could be due to the persistence of traditional gender roles where women care for children and the household, which may reflect unequal domestic responsibilities.8 Without children, men and women were equally likely to work LTFT, and female doctors with older children worked the same amount as their male counterparts.8 A policy brief published by the WHO in 2010 identified the importance of providing widely available flexible working arrangements for healthcare workers, as well as provisions for childcare for healthcare workers, in creating attractive and supportive working environments.21
Choice of specialty has a major influence on doctors’ decisions to work LTFT.9 UK figures have shown higher percentages of LTFT trainees in medicine, paediatrics, anaesthesiology and GP, with lower percentages in surgical specialties.9 Australian figures from 2009, detailing advanced trainees in LTFT training by specialty, reported that GP had the highest number of part-time trainees, followed by public health, emergency medicine (EM) and psychiatry. The lowest number of part-time trainees was in surgery (fewer than 5%), followed by anaesthesiology and adult medicine.10 The higher rates of LTFT training in GP likely reflect, at least in part, the workforce being largely female. Doctors are also more likely to choose GP for lifestyle factors, often prioritising work–life balance.8 Women are also represented more poorly in specialties with unpredictable work patterns.12
Apart from child-rearing, several other reasons have frequently been identified as leading doctors to pursue LTFT training. A 2016 UK survey revealed that the other most common reasons for considering LTFT training were caring for a dependent (12.6%) and sporting commitments (6.8%).16 In Ireland, applicants for LTFT postgraduate training must have ‘well-founded individual reasons’ for applying for one of the 32 funded ‘flexible training’ places available each year, with the most common reasons listed including caring responsibilities, health reasons and personal family circumstances.22 23 Other paid work, paid non-medical interests and engaging in research are not considered adequate, and participation is restricted to a maximum of 2 years working at 50% WTE.22 By contrast, in England since 2022, eligibility criteria have been revised to allow all doctors in postgraduate training to apply to train LTFT for any well-founded reason, including well-being and personal choice.24
A 2012 Australian study of obstetrics and gynaecology trainees found preparing for exams was a common reason to undertake LTFT training, with 40% of LTFT trainees listing this reason.17 Another study in the USA examined doctors’ reasons for pursuing LTFT training within one residency programme that provides a ‘flexible option’, allowing a broad range of reasons to work LTFT. Apart from childcare, reasons listed included time to perform research, pursuing international health work or other educational interests, supplementing income and mental health.18
From this worldwide literature, it is evident that a number of reasons influence decisions to train LTFT, and many of these reasons were not included in traditional restrictive eligibility criteria for LTFT training.25 75% of respondents to a 2019 trainee survey by the Royal College of Physicians of Edinburgh stated that trainees should not have to provide a reason in order to train LTFT.26 A WHO policy brief on supportive working environments for healthcare professionals advised that flexible working arrangements would help to reduce burn-out and loss of skilled staff from the workforce.21
Attrition is a significant problem for many postgraduate medical training programmes, in particular for surgery. Common factors that lead to attrition of hospital doctors are work–life balance, workload, lacking a sense of control over the job, personal reasons and culture of their chosen specialty.27 It has been suggested that female doctors’ interest in surgery decreases as they progress through their careers, with the most interest at medical student level, lower amounts of interest at junior postgraduate level and lower interest again at senior postgraduate level. Family commitments and long working hours are frequently cited as reasons for discontinuing surgical training. It has been proposed that increased availability of LTFT training could reduce this waste of surgical trainees, who are lost from training programmes.6 A Canadian study of surgical trainees found more than one-quarter were considering abandoning their surgical careers, mostly because of unsatisfactory work–life balance.28 Other Canadian data found that the most significant factors associated with thoughts of leaving surgical training were poor work–life balance (71%), concerns about future unemployment or underemployment (46%), poor quality of life (44%), sleep deprivation (50%), undesirable future lifestyle (47%) and excessive work hours (41.4%).29 In a 2007 systematic review of voluntary attrition among general surgical trainees in the USA, the most common cause was ‘uncontrollable lifestyle’.30 Medical students and junior doctors have reported feeling that surgical careers do not welcome women, due to lack of flexible training and poor work–life balance. There is a lack of awareness that LTFT training can be undertaken within a surgical career, and many trainees report choosing not to work LTFT for fear of bullying or undermining behaviour.11
In a large UK report on obstetrics and gynaecology trainees, LTFT trainees were more likely than full-time trainees to have a positive outcome in their annual review of competency progression (ARCP). LTFT trainees were more likely than full-time trainees to report that their personal training requirements were being met. 60% and 80% WTE were the most common working-time percentages among LTFT trainees; those who worked 70%–90% full time appeared to report a superior training experience when compared with other percentages, as well as compared to full-time trainees.3 LTFT trainees were also less likely to report bullying and felt less obliged to work beyond their contracted working hours.3 By comparison, LTFT training in Ireland (whether through the national supernumerary scheme or through ‘job-sharing’ pilots) is available only at 50% WTE.23 Another recent UK report by Health Education England found that 71% of LTFT trainees achieved a satisfactory ARCP outcome, compared with 45% of those training full time. 87% of LTFT trainees said they planned to work as consultants in the UK National Health Service, compared with 58% of full-time trainees. A majority reported that LTFT training had impacted positively on their well-being (77%), work–life balance (78%) and job satisfaction (57%). Educators and full-time trainees who were questioned for the report said that many LTFT trainees were better rested and had higher morale than full-time trainees. Educational supervisors felt LTFT training was not detrimental to their relationship with trainees or their ability to schedule meetings. A majority of LTFT trainees (52%) felt their model of training did not have a negative impact on service provision.31
Despite multiple advantages associated with LTFT training, a number of negative aspects have also been identified. In the UK, continuity of clinical care has been reported to be worse among LTFT trainees than their full-time counterparts. A report by Health Education England found that LTFT trainees feel less well supported by academic supervisors and felt less able to attend conferences and academic training opportunities.3 They also report a number of different concerns when deciding to undertake LTFT training, including financial concerns; negative perceptions of consultants and colleagues; impacts on the quality of training; extended training duration and uncertainty around the application process.31 These worries varied depending on how many WTE hours were worked by the trainee. Where trainees worked fewer hours (less than or equal to 60% WTE), they were more likely to feel that LTFT training might negatively impact team integration, whereas trainees working 80% WTE reported positive views on team integration.31 79% of educators felt that LTFT training impacted rotas negatively, with rota gaps being harder to fill where trainees were working 80% WTE, compared with rotas based on 50% WTE or ‘slot-sharing’ roles. 64% of educators felt LTFT training had a negative impact on service provision, again finding trainees working at 80% WTE to be the most challenging.31
Health Education England piloted a role entitled ‘Champion of Flexible Training’ in an attempt to resolve some of the identified issues. These are remunerated positions for clinical educators with formal allocation of non-clinical time, intended to aid with raising awareness of LTFT training, assisting educational supervisors and organisations, researching LTFT training performance and assisting LTFT trainees with any issues. This role succeeded in informing trainees of their options, correcting pay issues and reducing tensions between LTFT trainees and departments, to support both LTFT trainees and educators.31
There is a paucity of research on LTFT training in Ireland. One recent quantitative Irish study looked at the opinions of paediatric trainees on LTFT training, finding a significant lack of awareness of LTFT training as well as a number of perceived barriers, including LTFT post availability (49%), impact of LTFT on career progression (51%) and 50% WTE being the only available option for percentage of hours worked (54%). Trainees felt the scheme was restrictive, in that it is available for no more than 2 years per trainee, and they felt they would be rejected if the reason for the application was not parenthood. They also reported negative perceptions of LTFT trainees and difficulty integrating into clinical teams.32
Given the lack of Irish research on the topic, as well as the growing importance that is now being placed on LTFT training worldwide, this study aimed to explore how best to support LTFT training in Ireland as well as internationally.
Methods
This prospective qualitative study used semistructured interviews. A narrative interpretivist approach was adopted. The research group consisted of members of the training community at the Irish College of General Practitioners, Royal College of Surgeons in Ireland (RCSI) and College of Anaesthesiologists of Ireland. The group completed a background literature review and used this to develop research questions in order to generate a set of interview topic guides. These topic guides were tested by conducting mock interviews with a small cohort of doctors not otherwise involved with the study as well as lay persons. Feedback was obtained on the participants’ interpretation of the questions, the emotional impact of the questions, the thoughts that were evoked, and the clarity of the interviews. This was used to refine final topic guides (see online supplemental files 1–4). The topic guides prompted interviews under a variety of headings, including basic demographics, general knowledge of LTFT training, impact of LTFT training on career progression and well-being and perceptions of LTFT training. Details of the study design are further outlined in the protocol which has been included as online supplemental file 5.
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Recruitment
Data coding of completed interviews took place in parallel with ongoing recruitment of further participants. Sample size was determined by satisfying the two requirements of maximum variance: purposeful sampling and coding saturation.33 Recruitment continued until evidentiary adequacy was achieved when it became clear that further interviews were generating no further unique new codes. Purposeful sampling was used to satisfy, as far as possible, a predetermined range of maximum variance descriptors. For NCHDs, recruitment targeted the following categories: male and female; full-time and LTFT; early and late stages of training; a broad range of specialties; those with and without children; NCHDs currently not on training programmes; trainees with PMQs from various Irish and non-Irish medical schools; trainees with undergraduate-entry and graduate-entry PMQs. For other members of the medical community, recruitment targeted the following categories: medical educators/trainers/tutors in the hospital and community setting; postgraduate deans and faculty supervisors; consultants with no formal teaching role; training staff and leads within PGTBs and NDTP; medical manpower staff; postgraduate training leads. Participants were recruited from urban and rural settings, from secondary and tertiary hospitals, and across administrative, training and managerial roles, in order to ensure the research findings would be transferable across specialties and settings.
NCHDs in formal training posts with a PGTB were recruited indirectly, by volunteering in response to advertisements placed in NCHD trainee newsletters and other communication channels such as WhatsApp groups. The study was briefly described, and interested doctors were invited to make contact by email. A snowballing technique was also used, with responders asked to pass information on to colleagues who may be interested, in particular where better representation was needed from specific categories. Purposeful sampling was not used for NCHDs in training posts in order to avoid trainees perceiving any sense of coercion to participate, due to the involvement of PGTBs and NDTP in conceiving this study.
Other members of the medical community—including NCHDs not in training posts—were recruited not only through these advertisements but also by maximum variance purposeful sampling, either by direct invitation from the researchers or by emails forwarded via the PGTBs and the national network of medical manpower officers. PGTBs were asked to nominate deans and training managers. To protect privacy, any clinical supervisor who agreed to participate was paired with a research interviewer not previously known to them, affiliated to a different specialty PGTB.
The recruitment strategy was designed to maximise personal choice by participating in this research. Postgraduate trainees are the only research subjects for whom a significant power dynamic was relevant, as other potential participants would initially be approached by peers.
Data collection
Four researchers (CM, GBB, GJ and MA) conducted the interviews, either online using video-conference software (Zoom) or face to face. One researcher acted as data controller and was not involved in interviews, in order to maintain anonymity of participants and reduce the risk of bias in thematic analysis. The interviews took place between May 2022 and December 2022, ranged from 20 to 45 min in duration, and were recorded and transcribed by the research interviewers, by hand or using online software (Otter). The transcripts were sent to the data controller, anonymised, stored in keeping with the General Data Protection Regulation (GDPR) and imported into qualitative data analysis software (NVivo V.12) for subsequent analysis.
Participant information sheets and consent forms were prepared, addressing GDPR issues.
Zoom security features were used to protect the privacy of participants. Recordings of the meetings were saved to the local hard disk, rather than to the cloud and were deleted after transcription was complete.
The details of all the participants were stored by the data controller on an Excel spreadsheet on a laptop separate to that used for data analysis. The data were pseudonymised and stored on encrypted files on a password-protected computer for 2 years postcompletion of the study, prior to being destroyed.
A total of 29 interviewees took part, with summary statistics listed in table 1.
Summary statistics of interviewees (n=29)
Data analysis
Thematic analysis was used to identify themes and patterned meanings. Five researchers conducted line-by-line open coding of each transcript using NVivo V.12. Following sample coding of an initial batch of interviews, a common codebook with high inter-rater reliability was agreed through several meetings, to ensure a uniform coding approach by the multiple interviewers and coders involved. This codebook was then applied to all transcripts. 246 codes were condensed to a final number of 46. The researchers collaboratively grouped these codes into 16 key categories within 4 overarching themes, according to the principle of thematic analysis using an inductive realist approach.34 35 Findings were verified using reflective conversations (with each researcher considering how their experience affected thematic analysis), comparing the codes and revising the categories in the light of the research question over several meetings. The thematic code tree is presented in figure 1.
Thematic code tree. LTFT, less than full time.
Patient and public involvement
Patients and members of the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Results
We report below on the four themes of our findings, which are illustrated by quotes.
Flexibility of working structures
Current work structures for NCHDs are seen as inflexible. Legal entitlements like parental leave are often difficult to access, and as a result, many doctors with children felt compelled towards LTFT work.
Interview participants reported that ‘slot-sharing’ or ‘job-sharing’ posts—comprising one WTE role filled by two people, each working at 50% WTE—seemed easier to institute than other formats of part-time post, and they had the least negative impact on service provision and rostering. However, participants felt it important that neither doctor working in such a pair be specifically required to cover for the leave or absence of the other, and that the employer should remain responsible for service provision.
Administrative staff reported difficulties in finding locum cover for 50% WTE posts, and that their workload is doubled where two doctors are employed for a single WTE role. Most NCHDs expressed a desire to work more than 50% WTE. Many felt that restricting WTE options to only 50% would deter them from LTFT training; commonly cited reasons included reduced income, negative perceptions from colleagues due to short working hours and extended overall training duration. Some reported their ideal working pattern would be spread over 3–4 days per week.
Rostering was felt to be complicated by accommodating LTFT posts. This was considered less of a problem in shift-based specialties such as EM and anaesthesiology, or where rotations are longer than 3 months in duration. Some LTFT trainees reported they had to be heavily involved in creating their own rosters, and one reported missing out on a clinical rotation as the hospital department indicated it could not accommodate LTFT training. Opinions varied as to whether rostering LTFT trainees was easier in larger hospitals. Increasing the number of LTFT trainees might make rostering simpler due to a larger pool of staff.
Interviewees from all groups felt LTFT training has little impact on service provision. Continuity of care was a concern, especially in general internal medicine. Participants from all specialties felt that issues with continuity could be overcome using well-structured handovers. Many felt that time lost through more handovers could be offset by increased productivity, reduced burn-out and sick leave, and increased staff retention. It was suggested that continuity of care was affected more by attrition, leading to high staff turnover and the need for locum cover.
Administrative staff responded positively to the prospect of making LTFT training more available. They felt it was a necessary and overdue step in promoting retention of a skilled workforce, despite potential administrative difficulties, such as the increased workload in managing more individuals for the same WTE complement, calculating LTFT leave entitlements, and difficulty in finding locum cover for lower WTE percentages, especially in peripheral or rural hospitals. A particular problem is the calculation of overtime pay for LTFT doctors, as pay systems are generally set up for full-time employees, making this stressful and confusing for trainees and administrators. Administrators reported they would need increased resources and training to overcome this.
Illustrative quotes are listed in table 2.
Flexibility of working structures
Attitudes to LTFT training
Current LTFT trainees felt that LTFT training did not negatively impact career progression, although some full-time trainees expressed potential fears regarding this.
Most trainers and PGTB representatives spoke positively about the effects of LTFT training on quality of training and career progression. Participants felt career commitment may be increased by a more favourable work–life balance, and that attitudes to LTFT are rapidly changing compared with previous generations.
Participants felt that LTFT trainees became better integrated into the clinical team with time. LTFT trainees expressed initial discomfort due to limited understanding by colleagues of the nature of LTFT working, or even envy from peers due to better work–life balance. It was felt that, at first, LTFT trainees have less opportunity for social integration, but integration becomes easier as they demonstrate commitment. Integration was felt to be easier in training sites with more local experience of LTFT training.
Because LTFT trainees often spend longer calendar time than full-time trainees in any single training site, it was felt that their team integration may, ultimately, be better. Several interviewees felt strongly that the more widespread and normalised LTFT training becomes, the more negative attitudes towards it would reduce.
Illustrative quotes are listed in table 3.
Attitudes to LTFT training
Training bodies and LTFT training
Trainees felt that PGTBs could do more to promote awareness of LTFT training. Many NCHDs were unaware that LTFT training was possible. Some who had completed the application process suggested that workshops could be held to guide trainees. PGTB managers expressed concern at the current lack of support for accommodating LTFT trainees.
Trainees and trainers had mixed opinions of how LTFT trainees would effectively achieve their training competencies. Full-time trainees expressed fears they would struggle to achieve competencies if they trained LTFT. Doctors with experience of LTFT training felt they could achieve their competencies readily. Many agreed that competencies should be assessed on a case-by-case basis, irrespective of full-time or LTFT status, as each individual learns at a different pace. There was consensus that out-of-hours on-call commitments, in addition to normal daytime work, are necessary to achieve competency.
In some cases, trainees perceived an attitude from PGTBs that LTFT training might negatively impact their careers and allocated job rotations. Trainees felt that LTFT training seemed challenging and problematic for PGTBs to deal with. PGTBs will need to work with the HSE to establish patterns of LTFT training that can mutually benefit trainees and provide adequate service. PGTBs may need to be resourced to facilitate LTFT training.
Illustrative quotes are listed in table 4.
Training bodies and LTFT training
Work–life balance and burn-out
LTFT training was largely thought to reduce the risk of burn-out and improve work–life balance in medical careers. Caring responsibilities were commonly quoted as a reason for choosing LTFT training. Other reasons included interests outside of medicine and academic responsibilities. LTFT trainees expressed greater work satisfaction and appreciated more family time.
Trainees reported that they completed most of their training requirements in personal time outside of rostered hours. Some reported that LTFT training helped them to achieve academic requirements due to the reduced toll of service commitment. Others reported struggling to access training opportunities.
Participants felt some specialties such as EM, anaesthesiology and GP were more conducive to LTFT training than others. Some respondents reported they would not choose LTFT training because of prolonged training duration and/or reduced income. Several trainees with children were considering leaving their specialty or transitioning to a more flexible career such as GP, due to a lack of suitable LTFT opportunities.
Illustrative quotes are listed in table 5.
Work–life balance and burn-out
Discussion
The main findings of the study centred on flexibility of training structures, work–life balance and burn-out, training bodies and LTFT training and attitudes to LTFT training. Awareness surrounding LTFT training options was poor. Current working structures were seen to be inflexible, and there was a preference for increased availability of high WTE options. Accommodation of LTFT training was felt to increase administrative workload and create human resourcing difficulties, and there was a perceived lack of support in this area. LTFT trainees feel that they achieve their competencies readily but there is a fear of negative perceptions of LTFT training and the impact this may have on career progression. Recent Irish literature, and the adoption of the ‘quadruple aim’ to optimise healthcare by improving staff well-being, indicates an urgent need to address NCHD welfare in the Irish healthcare system, and facilitation of LTFT training is one potentially cost-effective strategy for this.36–39 Of the four overarching themes from the interviews, two themes (work–life balance and burn-out, and attitudes to LTFT training) were closely aligned with core topics from our interview topic guide, showing that the guide was effective in exploring key areas of interest. The other two themes (training bodies and LTFT training, and flexibility of working structures) were not so explicitly covered in the topic guide but appeared to emerge naturally through the interviews. This indicated the interview process was open and that participants felt able to share new insights not explicitly covered within the topic guide.
Work–life balance
There is a paucity of research on LTFT training worldwide, and in particular, there is a lack of qualitative studies. Previous international research has largely looked at reasons that doctors pursue LTFT training and at issues surrounding work–life balance; this study echoed previous research in that there was poor awareness among doctors regarding LTFT training,32 and family and caring roles were a common reason to pursue LTFT training, with attrition being high due to inflexible working structures.8 12 15 20 There has been a comparative lack of focus on the logistical and governance challenges associated with LTFT training, or the impact of these on the working environment. The idea of work–life integration may be even more relevant in the modern medical workforce than the concept of work–life balance. Work–life integration implies that work and life often occur simultaneously with blending of personal and professional responsibilities throughout the working day rather than keeping the two roles entirely separate. With many participants in this study suggesting that they wish to work higher WTE hours in order to fit in personal life tasks during their working week, or simply have access to limited parental leave days, it is clear that the idea of improved work–life integration should be considered as an aspirational goal in the design of future LTFT training structures.
Flexibility of training structures and administrative problems
Awareness of LTFT training structures was poor among participants. Current work structures were seen to be inflexible, with legal entitlements to parental leave difficult to access. Most trainees expressed a preference for higher WTE options such as working 80% WTE hours (or 4 days per week rather than 5), with commonly stated reasons for this being reduced overall years of training and impact on career progression. This echoes experience from the UK where doctors expressed concerns over financial shortfall and increased overall training time.7 This demand for increased flexibility in working hours was balanced by concerns around associated logistical difficulties, complicated rosters and increased administrative workload. LTFT trainees and administrative staff specifically perceived a lack of support for accommodating LTFT training. In the UK, LTFT training difficulties have been addressed by employing LTFT liaison officers who raise awareness, assist supervisors and trainees and research training performance.7 40 This role informed trainees of their options, corrected pay issues and reduced tensions. It can also be noted that PGTBs tend to be less resistant towards roles with part-time clinical hours where the body paying for the non-clinical component is perceived as being prestigious, such as for academic research fellowships through the Wellcome Trust or the Irish Clinical Academic Training programme.41 42 A survey of doctors who completed internship in Ireland in 2011 found that 45% were no longer working in the Irish public healthcare system by the following year.43 Failure to retain trained staff has led to increased spending on locums.36 Studies interviewing doctors in Ireland reported work–life balance was a major reason for emigration.36–38 Our study supports the assertion that LTFT training opportunities can promote better work–life balance and retention.
Competency and team integration
Most participants expressed positive attitudes towards LTFT training in terms of trainee competency, commitment and integration into the team. Full-time trainees feared they might struggle to achieve competencies if they trained LTFT. However, LTFT trainees felt they achieved competencies readily. Trainees feared that LTFT training might negatively impact career progression, and they would be seen as less favourable candidates for posts. Trainees were particularly concerned about the effect that working lower WTEs may have on career progression.
In UK and Australian literature, LTFT trainees were more likely than full-time trainees to be successful in their ARCP, supporting the sentiments of LTFT trainees in this study.3 7 Previous literature has reported negative effects of LTFT working on the training experience with poorer access to support and academic opportunities.3 44 A UK pilot project reported that the fewer hours they worked, the more difficulty LTFT trainees reported with team integration; trainees working more hours (80% WTE) reported positive views on team integration.7 Trainers in this study expressed similar concerns over ensuring equal access for LTFT trainees.
Service provision and continuity of care
While most NCHDs in this study expressed a preference to work more than 50% WTE, administrative staff felt offering other WTE options would complicate rostering and finding locum cover. Prior research showed that educators found 80% WTE the most challenging to maintain continuity of care compared with 50%.7 All interviewees in this study felt continuity of care could be maintained with structured handover systems. Many studies report concerns that LTFT training may negatively affect service provision, continuity of care and rostering.7 Educators felt LTFT training had a negative impact on rotas, with rota gaps being harder to fill where doctors work 80% WTE, compared with 50% WTE.7 It was felt that, although LTFT training may affect continuity of care in some specialities, this could be offset by increased productivity, reduced burn-out and sick leave and increased staff retention.
Strengths and limitations of the study
This study has a number of strengths. It had a qualitative design using semistructured interviews, which allowed deep insights into perceptions of LTFT training, avoiding superficial responses from other techniques such as surveys and allowing participants to clarify and follow-up on particular comments. Participants came from diverse backgrounds, which provided for a broad spectrum of opinions including not just NCHDs themselves but their consultant colleagues and those involved in facilitating postgraduate medical training.
There were limitations to the study. The final number of participants was limited, totalling 29. However, thematic saturation was achieved during the coding process, suggesting that further interviews would have been increasingly unlikely to identify meaningful new themes that had not already been coded and accounted for. NCHDs in formal training posts were recruited only indirectly, through advertisements on bulletin boards and in newsletters and circulars, in accordance with the ethical approval to avoid any risk of perceived coercion from PGTBs. The need for this cohort of participants to actively respond to these advertisements could mean that these respondents were more likely to have a pre-existing interest in LTFT training. It could also reflect under-representation of certain less numerous sections of the workforce within the participant cohort, such as female trainees with young families. This may partly explain why the study did not demonstrate a strong difference in the behaviour of women with children when compared with women without children and men—a statistical pattern which has been well-cited previously.8 15 The expressed opinions were, however, largely consistent with international literature.
As each transcript was coded by the same researcher who had conducted that interview, there was a risk that the researchers would remember the identity of some of the participants during the thematic analysis process (particularly in relation to unique or distinctive statements), which could be a source of bias. This risk is, however, common to all qualitative research, whereby the analysts are not usually blinded to the identity of participants, and it was judged that the risk was offset by the benefit of more thoroughly understanding the meaning of the statements being analysed.
Future qualitative research in this field should aim to be broader and more diversified, aiming for larger samples, including target demographics which are known to be under-represented in the workforce (such as women with young children), and including various jurisdictions to provide a more broad and deep understanding of experiences and perceptions about LTFT training. This would provide deeper insights and help in informing policy refinements and advancement in the field.
Conclusions
LTFT training appears to be a viable strategy to aid in solving issues currently faced in postgraduate medical training, with the potential to reduce burn-out and attrition, and improve the training experience, without major reported adverse effects on service provision. However, LTFT training cannot be shoehorned into inflexible structures which are designed for accommodating only full-time positions. The traditional solution of two trainees both working 50% WTE hours to cover a single WTE post is suboptimal for many trainees who would prefer to work between 60% and 80% WTE.
This study integrates qualitative data collected in Ireland with international qualitative and quantitative literature on LTFT training and contributes to the evidence that increased administrative support and dedicated variable-percentage LTFT posts are necessary. For example, the appointment of LTFT liaison officers may assist in bridging the gap between hospitals and PGTBs; active promotion of LTFT training among NCHDs and PGTBs could help to ensure stakeholders are well informed; and practical and financial supports such as review of payroll methods, and training and resourcing for manpower departments may also facilitate the practical aspects of these important system changes. LTFT training is crucial in the development of a more sustainable future workforce. Its expansion will inevitably incur substantial structural changes to postgraduate medical training and hospital systems. Successful implementation will require adequate planning and supports, as well as attitudinal change among stakeholders. While there is no evidence to suggest that LTFT has any significant negative impact on physician competency, these perceptions remain ingrained, and challenging them is vital in ensuring successful adoption of LTFT training.
Data availability statement
No data are available. To protect privacy of individual participants, the unedited interview transcripts are not publicly available. Anonymised data from the transcripts are available via the corresponding author on reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Research Ethics Committee of the ICGP (approval number ICGP_REC_22_006). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors acknowledge the invaluable contributions of Manuela Afrasinei, who passed away in April 2024. Her dedication to this research was deeply appreciated.
References
Footnotes
X @GBeecham, @AstonMMC
Contributors KH and MM conceived the study. All authors contributed to its design. CM, GBB, GJ and MA conducted the interviews, and MK acted as the data controller. KH acted as guarantor. All authors contributed to writing the paper and read and approved the draft manuscript. MA died in April 2024. All other authors approved the final manuscript for submission.
Funding This work was supported by grant number ICGP202 of the Development Funding 2022–2023 Cycle from National Doctors Training & Planning (NDTP), which is a unit of the Health Service Executive (HSE). Administrative support was provided by the Irish College of General Practitioners (ICGP), the College of Anaethesiologists of Ireland (CAI), and the Royal College of Surgeons in Ireland (RCSI). NDTP, ICGP, CAI and RCSI did not participate in study design, data collection, analysis, decision to publish or manuscript preparation.
Competing interests CM, MK, GJ, GBB and MA are doctors with an interest in LTFT training and are in postgraduate medical training programmes overseen by PGTBs. GJ is a LTFT trainee. KH and MM have senior roles within PGTBs that offer LTFT training (ICGP and CAI, respectively). MM is an executive member of the Forum of Irish Postgraduate Medical Training Bodies.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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