Of the sixteen interns who completed the internship programme, twelve participated in the evaluation (3 male, 9 female). One intern was too unwell to take part and three did not respond to the call to participate. The mean age of the interns participating in the evaluation at the start of their internship was 26 years, 1 month (range 20 years, 11 months – 36 years). The graduate profile of the interns was: six physiotherapists, four podiatrists, one occupational therapist and one nurse (Table 1). At the time of interview (September to December 2018), one intern was undertaking a PhD, one had a research component to her clinical role and 10 were in full time clinical positions. Of the 22 mentors approached to participate, 13 took part.
All interns participating in the evaluation had presented at least one oral or poster presentation at national / European rheumatology conferences, totalling 21 conference abstracts. Interns also made authorial contributions to three peer reviewed publications, with the number expected to rise as projects complete.
Analysis identified seven themes, clustered into three domains: 1) impact on careers, interns and practice, 2) drivers for applying, 3) evaluation of the internship design. Each will be described with illustrative quotations.
Impact of the Internship Programme
Impact on Career Pathways
Mentors and interns valued the programme as it provided an early ‘taster’ for high-achieving graduates who would not otherwise have access to research. As one intern commented, ‘it has allowed people such as myself, recent graduates in healthcare, to gain experience in research which would otherwise not have been possible without pursuing postgrad and research positions (not easy)’ (IT7). Many interns said they gained greater confidence when applying for jobs due to the ‘kudos’ of being an intern and the research and MSK knowledge the internship programme provided: ‘I’ve taken on the responsibility… as a sports physiotherapist, which prior to the internship I would have been apprehensive in committing to due to concerns over a lack of knowledge.’ (IT1).
Most interns said their perceptions of research had changed as a result of the programme. There was increased awareness that clinical academic careers were possible and not harmful to clinical careers, that research was accessible and not ‘elitist’, and that research was clinically relevant and not removed from practice: ‘I learnt what a clinical research career really looked like – working with patient partners and a wide clinical research team to improve patient care. Not just sitting in an office evaluating what has already been done’ (IT3).
The programme was a ‘game changer’ for interns entering research positions, providing valuable knowledge of the research process, greater familiarity of research environments, and an awareness of multiple pathways for research funding. For the ten interns in full time clinical roles, nine said they intended to continue with research in the near future. Furthermore, interns entering clinical roles reported that the MSK knowledge provided by the internship supported their subsequent career.
Interns reported a growth in confidence as a result of the programme: ‘I grew confidence in myself and my ability to achieve and overcome challenges through having ownership of my project and needing to solve problems and project manage myself’ (IT12). Interns also gained confidence through presenting research and networking with academics and clinicians. They also commented that the programme improved their personal effectiveness, resulting in an ability to manage workloads and to communicate effectively and confidently with colleagues: ‘I have been able to use skills that I feel I developed during my internship, such as critical thinking, problem solving, project management, time management and the ability to communicate with staff and my seniors’ (IT12).
Impact on clinical practice
Interns entering clinical posts described how the programme improved clinical activities through an awareness of evidence based practice and an ability to access relevant information. One intern explained, ‘I am better able to evaluate research and incorporate it into my practice… When looking into creating an injury prevention exercise program for athletes, I used evidence to guide the structure and content, being able to run quick effective searches and quickly sift through endless articles and find the good pieces of evidence’ (IT5). Interns similarly described an improved ability to undertake Quality Improvement and audit, and a deeper understanding of patient-centred care, enhancing the appropriateness of treatments offered: ‘my exposure to service users was really valuable and complemented my clinical experience of trying to make treatments patient centred… I am more aware of ensuring that my treatments are patient centred in design and execution’ (IT5).
The increased confidence noted earlier also improved practice, with interns being able to question and clarify diagnoses and treatment options: ‘I am a lot more confident in my ability to take on responsibility and communicate effectively with others… I’m not afraid to speak with members of the MDT to share my knowledge’ (IT1). Interns also said the knowledge gained of rheumatological symptoms, diagnoses and treatments had improved their clinical practice. As one mentor described, ‘even those interns that do not end up working in rheumatology, the internship gives them essential skills that they can use in practice and become “champions” for rheumatology in their respective work’ (ME5).
Drivers for applying
Principal drivers for applying to the internship programme included an interest in research, a desire to attain a deeper understanding of research processes, and a wish to gain a ‘flavour’ of academia whilst considering career options. As one intern described, ‘I knew I was unable to embark on a clinical academic pathway straight from university due to financial constraints at the time, and the internship was a great option. I got to experience what a real-life research environment was like’ (IT4).
Interns believed that research and clinical knowledge gained through the internship would strengthen their subsequent careers. A knowledge of research processes, such as ethics applications and quantitative / qualitative skills, was thought to be helpful for those wishing to apply for academic / clinical academic posts. Similarly, an understanding of MSK health was thought to be helpful for those wishing to further their clinical careers. Furthermore, interns hoped a deeper understanding of evidence based practice would enhance their clinical activities.
All intern mentors agreed that the application process had been successful in recruiting interns with a commitment and capability for MSK research: ‘those who make it onto the internship programme are driven and ambitious and have already developed a thirst for research for what it can bring to clinical practice’ (ME7).
Evaluation of Internship Design
Design of the Intervention
All interns and most mentors said the timing (post-graduation and pre-first post) and duration (eight weeks) of the placement was optimal, resulting in an internship that was ‘intense’ and ‘ambitious’, yet feasible. It was suggested that fewer than eight weeks would not provide sufficient breadth of experience and would make project deliverables unachievable. Conversely, extending the placement could deter graduates from applying as this would delay the start of clinical / academic posts: ‘eight weeks was a manageable amount of time – any longer may have put me off applying and you wouldn’t be able to get the full internship experience if it were shorter’ (IT3).
Most interns valued the programme’s training days and said they provided an effective introduction to career development, research skills and MSK health. Visiting sites were highly valued as they provided an experience of research and clinical expertise at each location whilst strengthening a sense of intern ‘community’. Most interns welcomed the opportunity to work in research teams, providing an insight into the ‘lived reality’ of research life.
Leading a research project to completion was important to interns, and thus the selection of research projects was integral to the programme’s success. The internship was most rewarding where intern involvement was meaningful: ‘I didn’t feel like a data monkey. I was there to learn and grow’ (IT9). Mentors and interns recognised the challenge of identifying topics that were sufficiently ambitious yet achievable within the timeframe of the progamme. Failing to identify a suitably ambitious project would have limited the value of the internship experience.
Mentorship and Networking
The programme provided formal mentoring from experienced health researchers and facilitated peer support from interns. Most interns valued the support provided by mentors, particularly their advice on career pathways: ‘mentorship and continued support during and after my internship was absolutely pivotal in allowing me to progress my clinical research career’ (IT3). Mentors reported that hosting interns was a significant investment of time, although all had the experience and capacity to support the programme.
It was evident that the interns developed an effective, supportive community during the programme. As one mentor put it, ‘do not underestimate the power of the peer support network, not just within the eight-week placement, but way beyond’ (ME8). Interns spoke of the ‘lifelong’, ‘invaluable’ and ‘encouraging’ support provided by fellow interns, enabling challenges, opportunities and aspirations to be shared whilst motivating those participating in the programme. The distinction between intern and mentor began to erode over time with previous interns becoming ‘ambassadors’, actively promoting the programme and supporting new graduates. A challenge for the programme was thus providing effective mechanisms for long-term networking.
Challenges and areas for improvement
Involving 22 mentors across five sites provided a wide range of research and clinical expertise. However, it became apparent that not all shared a common understanding of the programme’s philosophy. Whilst most mentors understood the purpose to be, ‘about offering opportunities and developing the next generation’ (ME2), a minority thought it was primarily focused on research skill development. There is a need therefore to ensure consistent communications are given to mentors.
A challenge identified by interns and mentors was maintaining research interest and completing research activities whilst in full time clinical positions. Interns in clinical roles typically reported a lack of research interest from their clinical teams. As one mentor explained, ‘As newly qualified personnel, their clinical lives are incredibly busy, but also their employers are keen for them to focus on consolidating and learning new clinical skills, so they are very reluctant to free them up for regular mentor sessions, speaking at intern events or moving into higher degrees’ (M6). Consequently, interns spoke of their frustration at being unable to continue with research: ‘I would love to continue research as I am really passionate about it and I enjoy it, however I am not sure how this fits in with working full time and progressing clinically’ (IT8). Interns spoke of feeling ‘anxious’ and pressured as research tasks had to be undertaken outside their clinical work. As one mentor described, ‘the reality of clinical practice can scupper the best laid plans for future work on an incomplete project’ (ME6). Solutions proposed included the careful selection of research projects, increased mentor support, and close engagement with future clinical host organisations.
Another challenge identified by mentors was an underrepresentation from occupational therapy and nursing applicants. One mentor commented on the need for a, ‘targeted promotion to nursing students who constitute the majority of the rheumatology workforce but are minimally represented in the internship programme’ (ME5). A particular problem in attracting nurse graduates was the incompatibility of the timing of the programme with cycles of graduation at some HEIs, with the effect that some nurses would already be in employment by the time the internship started. Solutions to this problem included improved marketing and use of social media and running two cycles of the programme each year.