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Using paradox theory to understand responses to tensions between service and training in general surgery.

Cleland, Jennifer; Roberts, Ruby; Kitto, Simon; Strand, Pia; Johnston, Peter


Jennifer Cleland

Simon Kitto

Pia Strand

Peter Johnston


Context: The tension between service and training in pressured health care environments can have a detrimental impact on training quality and job satisfaction. Yet the management literature proposes that competing demands are inherent in organisational settings: it is not the demands as such that lead to negative outcomes but how people and organisations react to opposing tensions. We explored how key stakeholders responded to competing service–training demands in a surgical setting that had recently gone through a highly-publicised organisational crisis. Methods: This was an explanatory case study of a general surgery unit. Public documents informed the research questions and the data were triangulated with semi-structured interviews (n = 14) with key stakeholders. Data coding and analysis were initially inductive but, after the themes emerged, we used a paradox lens to group themes into four contextual dimensions: performing, organising, belonging and learning. Results: Tensions were apparent in the data, with managers, surgeons and trainees or residents in conflict with each other because of different goals or priorities and divergent perspectives on the same issue of balancing service and training (performing). This adversely impacted on relationships across and within groups (belonging, learning) and led to individuals prioritising their own goals rather than working for the ‘greater good’ (performing, belonging). Yet although relationships and communication improved, the approach to getting a better balance maintained the ‘compartmentalisation’ of training (organising) rather than acknowledging that training and service cannot be separated. Discussion: Stakeholder responses to the tensions provided temporary relief but were unlikely to lead to real change if the tension between service and training was considered to be an interdependent and persistent paradox. Reframing the service-training paradox in this way may encourage adjusting responses to create effective working partnerships. Our findings add to the body of knowledge on this topic, and will resonate with all those engaged in surgical and other postgraduate training.


CLELAND, J., ROBERTS, R., KITTO, S., STRAND, P. and JOHNSTON, P. 2018. Using paradox theory to understand responses to tensions between service and training in general surgery. Medical education [online], 52(3), pages 288-301. Available from:

Journal Article Type Article
Acceptance Date Sep 6, 2017
Online Publication Date Nov 6, 2017
Publication Date Mar 31, 2018
Deposit Date Jan 29, 2020
Publicly Available Date Jan 30, 2020
Journal Medical Education
Print ISSN 0308-0110
Electronic ISSN 1365-2923
Publisher Wiley
Peer Reviewed Peer Reviewed
Volume 52
Issue 3
Pages 288-301
Keywords Training quality; Job satisfaction; Tension; Service; Training; Health care environments; Stakeholders
Public URL


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