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Abstract
Introduction The concept of generations and generational diversity in the workplace is a widely discussed phenomenon in popular culture, organisational articles and research studies. A number of non-medical and medical organisations have attempted to identify generational differences among their workforces and devise solutions to overcome this. The impact of generational differences among the medical workforce, specifically postgraduate doctors-in-training (PGDiTs), in the National Health Service (NHS) has not been studied.
Method and analysis This qualitative study will use a pragmatic study methodology with components of grounded theory and interpretative phenomenological analysis to explore and understand the concept, perceptions, experiences and sources of generational diversity among PGDiTs working in the NHS. Six focus groups will be conducted with PGDiTs recruited from a single acute NHS Trust. Participants will be stratified according to their generation (ie, Generation X, Y or Z). Two focus groups will be conducted for each generation. If insufficient participants are recruited for a focus group, then one-to-one interviews will be offered. The data from the focus groups and one-to-one interviews will be analysed using an inductive thematic analysis method using NVivo software.
Ethics and dissemination This study has received approval from the Health Research Authority and Care Research Wales (Reference: 24/HRA/0770). Ethics committee approval is not required as the study involves NHS staff as research participants. The findings from this study will report a number of higher level themes reflecting the views and experiences of the research participants. The findings will be disseminated via academic conferences and peer-reviewed publications.
- Organisational development
- Human resource management
- QUALITATIVE RESEARCH
- Delivery of Health Care, Integrated
- Physicians
- Interprofessional Relations
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- Organisational development
- Human resource management
- QUALITATIVE RESEARCH
- Delivery of Health Care, Integrated
- Physicians
- Interprofessional Relations
STRENGTHS AND LIMITATIONS OF THIS STUDY
Protocol for a pragmatic qualitative research study aiming to explore and understand the concept, perceptions, experiences and sources of generational diversity among postgraduate doctors-in-training (PGDiTs) in an acute hospital setting of the National Health Service (NHS).
A key strength of this study is analysing and reviewing the perspectives of multiple generations of PGDiT and using focus groups and interviews to explore and understand their experiences in more detail.
Findings may be limited by the small sample size of this study and limitations imposed from purposive, convenience and snowball sampling and the self-selecting healthcare professionals who volunteer to take part in the study.
Although this study will provide rich and important data into the experiences of generational diversity in the NHS, generalising these findings to other regions of the UK and other countries may not be possible.
Introduction
According to Mannheim, each generation is a cohort of individuals sharing distinct social, cultural, political and technological events during their formative years, leading to shared perspectives and characteristics.1 Generational diversity (intergenerational differences, generation gap) refers to the different attitudes, values, behaviours and expectations of each generational cohort. Workplace interactions between different generations generate varying perceptions of one another, leading to stereotyping, preconceptions and tension.2 3 This can generate conflict which can be considered as ‘the process which begins when one party perceives that another has frustrated, or is about to frustrate, some concern of the first part’.4 Numerous cultural factors have been demonstrated to contribute to practices conducted within an organisation that promote institutional failure,5 with human factors being a key component of violation-producing conditions of ‘human error’.6 It is reasonable to consider that generational diversity within an organisation may impact organisational culture through differing views impacting team dynamics, training, working conditions, mentorship and supervision and staff retention.
Scholarly research has attempted to investigate the true nature, sources and impact of generational diversity within organisations with a view to identifying strategies to manage these differences. A broad range of methodologically diverse research studies have suggested differences in personality traits, work values and attitudes, communication styles, career patterns, leadership preferences and behaviours and teamwork preferences.7 8 The true magnitude and importance of generations and generational diversity and its impact in the workplace remains unclear and mixed, yet existing stereotypes held by individuals may still influence perceptions and actions of others, resulting in conflict in the workplace.3
Research on generational diversity among doctors has been conducted globally, yet these studies predominantly consist of opinion pieces, interviews, surveys and questionnaires. These studies report younger generations desiring greater work–life balance, different work values and priorities9 10 and differing interests in certain conditions.11 A recent study in North America explored ‘generational communication’ among physicians in the emergency department, with 70% of its respondents reporting observing conflicts due to generational differences in communication.12 Seven themes of conflict were identified with perceived differences in work ethic, treatment approach, technology application, entitlement, professionalism, work life balance and communication style. A number of strategies were generated by the respondents focussing on clarity of policies, training and communication practices to mitigate against conflict and maximise effectiveness.12
A qualitative research study conducted in Switzerland interviewed head physicians, resident physicians and attending doctors, stratified into Baby Boomers and Generation Y (Millennials), respectively. This identified differences in demands for communication style and information, feedback and leadership communication between the two generations.13 Further work by this group identified that the tone of communication, information quality and provision of feedback positively influenced the job satisfaction of all generations of physicians, with a greater impact on younger generations.14
Resident doctors within the National Health Service (NHS) face numerous challenges, ranging from difficulty in staff recruitment and retainment, workforce shortages, concerns relating to workforce planning, training conditions and employment terms and conditions, alongside experiencing poor morale and increasing levels of burnout, fatigue and mental health disorders.15–18 The exact cause of these challenges is multifaceted, and the existence and impact of generational diversity among this cohort is not clear.
The Nuffield Trust’s recent analysis of 20 years of NHS staff surveys has reported divergent experiences of working in the NHS between its younger and older members of staff.19 Yet the systematic investigation of generational diversity in the NHS has been limited, despite the NHS Long Term Workforce Plan acknowledging the use of tailored approaches to staff recruitment and retention across the generations, alongside recognising generational differences of the workforce towards training and flexible working.20
The Mind the Gap report is the only study that has investigated generational differences in the NHS. This study investigated the requirements of early career (Generation Y) midwives and nurses, focusing on their needs and expectations within the workplace. This report takes a further step forward by providing relevant stakeholders with recommendations and an adapted Maslow’s hierarchy of workplace needs as a framework to improve recruitment, progression and retention of this cohort.21 Archer et al. identified differing attitudes and preparedness of NHS Doctors’ towards revalidation, with differences in professional identity originating from generational differences emerging as a contributory theme, although no further analysis was performed on what these differences are and from where they may arise.22
To the best of our knowledge, no systematic investigation of the existence or impact of generational diversity in the workplace has been conducted among doctors in the NHS. Given the unique factors of training pathways and workforce terms and conditions affecting resident doctors in the NHS, applying lessons learnt from other types of healthcare professional in the NHS is limited. Furthermore, the applicability of research into generations and generational differences from one country to another is limited due to each nation experiencing and interpreting national and global events individually.23 The NHS Constitution is clear that its staff must be treated with respect, dignity, compassion and care to ensure that staff feel valued, empowered and supported, not just because it is the right thing to do, but patient safety, experience and outcomes are improved when this is achieved.24 It is well recognised that a positive organisational culture is associated with operational performance and success,25 and within healthcare, this includes improved clinical-related and staff-related outcomes, the latter including staff retention and performance.26 27 This reinforces the requirement to understand the experiences of resident doctors in their working environment.
The total number of doctors in the UK is increasing,28 with postgraduate doctors in training (PGDiTs) making up 24.6% of the medical workforce. The PGDiT cohort currently spans three generations (Generation X, Generation Y (Millennials) and Generation Z (iGen, Gen Z, Zoomers)) across a breadth of ages ranging from a 23-year-old newly qualified foundation year 1 doctor to a senior registrar in their late 30s with up to 10–14 years of postgraduate training. These three generations closely interact with consultants, specialty and associate specialist doctors and general practitioners (GPs) that are predominantly Baby boomers, Generation X and slowly rising numbers of Generation Y.
Given the lack of dedicated primary research on generational diversity within the medical profession of the NHS and increasing concerns relating to training and retention, there is a requirement to determine the existence and impact of generational diversity among PGDiTs in the NHS and identify potential solutions to improve intergenerational collaboration in the workplace.
Aims and objectives
This study aims to explore and understand the concept, perceptions, experiences and sources of generational diversity among PGDiTs working within a single acute hospital NHS Trust.
Methods and analysis
Study design
This is a qualitative research study. The study methodology supporting our study design is pragmatic, with components of grounded theory and interpretative phenomenological analysis (IPA) complementing one another. Grounded theory allows for the emergence of new themes regarding generational diversity,29 while the philosophical approach provided by IPA will provide a deeper insight into how lived experiences of research participants shape the experiences and interpretations of workplace interactions.30
Study setting and eligibility criteria
This is a single-centre study based at an acute hospital NHS Trust in the South of England. The following criteria must all be met for a participant to be included in the study: (1) any medically qualified healthcare professional with a General Medical Council registration number, (2) working in a recognised training programme in a specific acute hospital NHS Trust in the South of England, (3) currently based at that specific hospital and (4) consents to being interviewed and recorded for the purposes of the study.
The nomenclature that refers to non-consultant or GP grade doctors is confusing and has recently been altered from junior doctor to resident doctors.31 The term resident doctors refers to all locally employed doctors and PGDiTs. This research study is specifically recruiting PGDiTs as they have a clear relationship with their superiors within their training programme.
Data collection
Focus groups will be used to explore participants’ experiences and understanding of generational diversity through the sharing of experiences and personal anecdotes.32 The concept of a generation is defined by shared values and experiences,33 34 and the use of a focus group will facilitate an in-depth exploration and clarification of views and attitudes through social interaction.
Participants will be stratified according to their generation based on generational definitions with a view to conducting a total of six focus groups (Generation X (1 January 1965–31 December 1980), Generation Y (1 January 1981–31 December 1995) and Generation Z (1 January 1996–31 December 2020)). No clear consensus exists on generational cohort definitions. These dates have been chosen from reviewing a variety of sources.21 35 36 Each focus group will consist of three to six participants. Two focus groups will be performed for each of the three different generations, providing a total sample size ranging from 18 to 36 participants. We aim to achieve data saturation with this number of participants and discussions.37
Focus groups will be conducted face to face on the acute hospital NHS Trust premises at a mutually convenient time for the participants. Each focus group will be electronically audio recorded and led and moderated by the lead member of the research team (MC). All participants will be provided with a participant information sheet and will be asked to complete and sign an informed consent form prior to starting the study.
If there are insufficient participants recruited to conduct a focus group (minimum three participants), then semistructured interviews will be offered to the participants as an alternative option. Every effort will be made to conduct focus groups; however, one-to-one interviews are also frequently used in qualitative research.38 If a one-to-one interview is performed, the same approach to the focus group will be applied to the conduct of one-to-one interviews. Furthermore, if a mutually agreeable time or location is unable to be identified for the participants, then virtual focus groups or interviews will be offered.
An interview schedule will be developed with broad open-ended questions in various topics derived from prior research to help guide the focus groups and interviews.39 Internal pilot and informal field testing of the interview schedule will be conducted to identify any ambiguities, leading questions or interviewer biases, alongside guiding the order of the questions.40 The interview schedule will remain flexible and amenable to change as data collection continues, as other important topics may be raised through discussion with research participants. Reflective notes will be made by the moderator throughout the period of data collection.
Recruitment and sampling
The primary method of sampling will be purposive. Email communication will be used via dedicated email distribution lists that exist to contact all relevant medical professionals, specifically PGDiTs, working in the acute hospital NHS Trust. This initial email communication will contain an electronic copy of the participant information sheet and informed consent form. Potential participants will be invited to respond if they are interested and meet the predetermined eligibility criteria. If a potential participant would like to take part in the study, the research team will provide an opportunity for questions about the study. At this point, the research team will require the date of birth of the participant to allow generational stratification. The participants will then be provided with a variety of dates and times for a focus group or interview.
If purposive sampling fails to achieve sufficient recruitment of potential participants, then non-probability forms of sampling will be employed to achieve further recruitment, specifically convenience and snowball sampling. This may be by word of mouth or by email. With snowball sampling, the study participants will be strongly informed not to provide any details of potential participants to the research team to avoid the disclosure of any personal information. The exact demographics of the medical workforce are unclear; however, a report in 2019 identified that 3% of junior doctors working in secondary care were aged 45–54 years old.41 This represents Generation X, and this cohort is more likely to require early non-probability sampling in the participant recruitment phase.
Data analysis
All electronically audio recorded data will be fully transcribed verbatim. Transcripts will be anonymised and checked in comparison to the original audio recording prior to being uploaded into qualitative data analysis software (NVivo, Lumivero, Denver, USA).
Inductive thematic analysis will be used as the method to analyse the data. The main researcher will gain an initial familiarisation with the dataset prior to the generation of initial codes from transcripts.42 Approximately 20% of the transcripts will be independently coded by another member of the research team to establish intercoder reliability.43 The coding will then be compared between coders, and further discussion will continue until a consensus is reached. Initial codes will be inductively collated into various themes, with ongoing refinement of the themes into higher level themes and categories that will enable conclusions and potential recommendations to be generated.
The primary method of data collection in this study is through the use of focus groups. The concept of a generation is determined by shared values shaped by collective experiences. Therefore, it is considered that focus groups will be more effective at an in-depth exploration of shared experiences and views through social interactions among a generational group of participants. However, it is recognised that focus groups may not be possible and individual interviews may need to be conducted. If this occurs, this will be acknowledged as valuable as using different data sources contributes to data source triangulation, which increases the rigour and validity of the study.44
The data analysis strategy for two different data sources will be as follows. The data will be handed, transcribed and formatted in the same manner and coded using inductive thematic analysis. Each dataset will be coded independently, with a second member of the research team independently coding a proportion of transcripts from each type of data source. The codes and emerging themes from each data source will be cross-referenced and compared with identify divergent and convergent findings. A matrix will be created for each data source to visually demonstrate the findings, and a narrative synthesis will be conducted to explore and interpret these findings. Different data sources will be clearly acknowledged in the results and final report.
Respondent validation will be performed after each focus group or interview and after the final data analysis to check the accuracy of the transcriptions and whether the conclusions of the research team are consistent with the experiences of the participants.45 Respondent validation is not mandatory, and the participant can choose to opt out of this process.
The main researcher (MBC) will employ prospective reflexivity to reduce the impact of bias during the research process, data collection and analysis.46 47 This will be achieved practically by the guide provided by Olmos-Vegas et al45 that encourages reflexivity on personal, interpersonal, methodological and contextual factors that may influence the study. This includes the creation and maintenance of a reflexive journal throughout the study, alongside documenting the main researcher’s position and demographics, pre-existing assumptions and the consideration of any differential power dynamics between the participants and the interviewer. Various methodological frameworks for the study design were discussed among the research team prior to the adoption of a pragmatic approach. Regular contact with the research team throughout the study will be maintained to discuss and challenge any interpretations and assumptions and identify any blind spots in the study. The Standards for Reporting Qualitative Research and Consolidated criteria for Reporting Qualitative Research (COREQ) checklists will be employed for reporting the research study.36 48
Limitations
There are numerous limitations encountered within this study. This study will be conducted in a single acute hospital with its own regional characteristics and differences in comparison to other regions. This may result in different experiences and perspectives compared with other contemporaries in other hospitals and regions. The small nature of the study will also limit the generalisability of the study findings to the wider population of PGDiTs. Trainers and locally employed doctors have not been included in this study.
To overcome this, further research could be conducted among these additional cohorts, different healthcare settings (ie, primary care) and geographical locations, and with other specialties not represented in this study to capture a broader range of perspectives. The results of this study could be used to tailor the interview schedule for future focus groups and interviews with different participants and settings.
A number of biases are also likely to be encountered, including recall bias (ie, incorrect or inaccurate recollection of experiences and events) and a selection bias of those wanting to be included within the study. We anticipate difficulty in recruiting participants from Generation X as there are likely to be fewer individuals of this age working as PGDiTs.
Patient and public involvement
There was no patient or public involvement in the development of the protocol. A number of PGDiTs reviewed and contributed to the development of the initial participant invitation email.
Ethics and dissemination
Approval from the Health Research Authority (HRA) and Health and Care Research Wales was obtained on 6 March 2024 (Reference: 24/HRA/0770). The study end date is 31 August 2025. The HRA states that Research Ethics Committee approval is not required as the study involves NHS staff as research participants by the virtue of their professional role. All potential participants will be provided with a participant information sheet. Informed consent will be obtained from all participants prior to participating in the research study. Written informed consent will be obtained from face-to-face focus groups and semistructured interviews, or electronically completed consent forms will be completed from video interviews. All focus groups and semistructured interviews will be conducted at a time and place that is convenient to the participants. Participants will be reminded of their right to withdraw from the study without there being any negative consequences on their work or training. The importance of anonymity and confidentiality will be highlighted to participants and must be maintained during and after their participation within the research study.
All data will be handled following the UK Data Protection Act (2018), the Research Governance Framework for Health and Social Care and the General Data Protection Regulations (2018). Written informed consent forms will be stored in a locked cabinet in a locked office available to the chief investigator (MBC). An encrypted electronic audio recorder will be used to record the interviews and focus groups. Recordings will be removed from the portable device permanently as soon as they are transferred. The transcribing will be performed by the chief investigator. Interview transcripts will be pseudonymised and any personal information will be removed from the data prior to the data analysis. Participants will only be identified using a study identification number. Pseudonymised data and the study identification log will be stored in two separate access-restricted folders. Access to the data will be restricted to the research team only. The final study report will be circulated to all participants who have consented to receive the report and circulated to all relevant stakeholders. The findings of the study will be reported through relevant academic conferences and peer-reviewed publications.
Ethics statements
Patient consent for publication
References
Footnotes
X @neuroMBC
Contributors MBC is the chief investigator for this project. MBC developed the original idea for the project, further developed by JT, IH, LJH, SY and PS. MBC drafted the first version of the protocol with critical revisions by JT, IH, LJH, SY and PS, alongside giving approval for submission of the manuscript. MBC reviewed the manuscript and approved the final version. Guarantor: MBC.
Funding MBC has conducted this study within his position as an NHS England Southwest Leadership Fellow. During this time, MBC has been on secondment to NHS England Southwest. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, NHS England or NHS England South West.
Competing interests None declared.
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.