This study explored the positive and negative experiences of interns. This is important for those involved in delivering training for junior doctors [33]. Having senior doctors and other work colleagues who treat them well was considered imperative for a supportive workplace. Previous studies have also shown that when they feel supported, junior doctors are likely to enjoy their work and learn more [33, 34].
Stressful situations are commonplace in medical practice and junior doctors are more than likely to encounter them [9, 10, 35, 36]. Our findings add to previous literature on the causes of stress among junior doctors such as heavy workloads and conflict in the workplace, [10, 11]. What this study adds is a general lack of support systems in the workplace resulting in interns feeling unsupported. Easily accessible support in a time of crisis and stress management strategies are not commonly available for interns in hospitals [37]. Even when support systems are in place, they are often not very useful.
It is well known that workplace bullying is consistently associated with reduced mental health [38] and bullying of junior doctors is ubiquitous in the workplace. It is also recognised that very few junior doctors report on bullying due to factors such as fear of reprisals and impact on one’s career [39–42]. However, even in the absence of bullying, the work environment can still be unsupportive. The findings of this study suggest that senior doctors need to go a step further and ensure that junior doctors are treated well – that they can feel free to ask questions. Interns are particularly vulnerable in their first rotations. However, this inexperience does not appear to be considered when they are rostered [43]. Hence a new intern who gets posted to a busy department that has little in the form of supervision and mentoring might feel a considerable amount of stress.
Interns also described the different types of quality supervision. Previous studies have indicated that good supervision determined the ability of junior doctors to recognise and respond to patient deterioration [44] and resulted in them undertaking an increased number of activities [45]. However, types of supervision vary widely and there are no clear standards for supervisors or on what is expected of those who are supervised [46]. Nonetheless, some suggest that supervision must include creating pleasant learning environments and stimulating junior doctors to learn and function independently [47].
The Australian Curriculum Framework for Junior Doctors states that interns need to be provided with effective supervision, which means supervisors being available, offering learning opportunities and supervision according to the learner’s competence and confidence as well as being a role model [48]. These aspects were highlighted by interns in this study. Hospital consultants routinely supervise registrars and junior doctors but rarely receive training in supervision [46].
Interns also described different types of good teaching. This included the regular routine teaching sessions conducted by the hospital, teaching on rounds and after hours teaching. The emphasis however, was more on teaching that was relevant even if not very detailed. A good clinical teacher is knowledgeable, competent, caring, professional, and motivating [49] and although most clinical teachers are interested in teaching, only a small fraction have actually received any teacher training [50, 51]. Our findings concur with previous studies in that those teachers who were interested in teaching junior doctors found ways to do so.
Previous studies have indicated that a rural placement is an excellent way to learn medicine, [52–54] and develop a disposition to practice in rural areas [55]. Our findings concur with previous reports [55] in that there tends to be better clinical exposure in rural areas [54] making it a good place to start one’s career.
Herzberg’s theory and job satisfaction of interns
According to Herzberg, themes about satisfaction (motivating factors) are not the same as themes about dissatisfaction (hygiene factors) [23]. For instance, themes such as good teaching and advantages of rural internship which related to advancement and achievement (motivating factors) were different from themes such as unduly stressful working conditions and poor access to administration which related to working conditions and administration (hygiene factors). Except for two themes, namely supportive work environment and poorly organised teaching sessions, the results of this study held true for Herzberg’s theory. Nonetheless, it is important to note that during their internship, junior doctors are still learning their role and building their competencies. They are also learning the subtle hierarchies in the workplace. The work environment is therefore inextricably linked to learning [33] which is perhaps the essence of internship and could be considered a motivating factor.
Furthermore, although supervision is traditionally a hygiene factor, in this study it was considered a motivation factor because the role of the supervisor in internship relates more to that of a teacher. Hence the responses such as ‘being spoon-fed’, having autonomy, being able to ask questions and being taught. Although internship might not be considered a part of traditional education, it essentially teaches interns how to translate their theoretical knowledge into practice and work in a team environment. More often than not, the internship experience together with the people they are influenced by, determines a doctor’s future career pathway. It is therefore vital for internship coordinators to facilitate a positive internship experience.
Herzberg’s motivation hygiene theory is not without criticisms [23, 26]. Nonetheless, it makes a valuable contribution to human resource development by identifying factors that impact upon employee satisfaction [26]. A limitation of this study is that the number of interns was small and the study was restricted to one region. Geography, setting and culture might play a role in determining motivating and hygiene factors. However, the findings of this study can provide a starting point for health care managers when considering ways to improve experiences of interns.