Understanding why resident doctors leave the NHS and what can be done to retain them: A realist synthesis

Junior doctors, particularly those outside of formal training programmes, are choosing to leave the NHS. Previous research identified several causative factors including: feeling undervalued and unable to deliver good patient care; poor learning opportunities and support; and a lack autonomy, flexibility and work-life balance (Lock and Carrieri, 2022; Church et al., 2023; Church and Agius, 2021). This complex problem has significant repercussions for service provision, patient care and NHS finances. In response, the NHS Long Term Workforce Plan proposes to ‘train new staff, retain existing staff and reform education’ (NHS England, 2023), with doctors clearly identified as a focus area. Improved retention of existing staff is central to the Plan, as training new staff will be a wasted investment unless they are retained, but the detail of how this will be achieved is currently unclear. This research aims to understand why junior doctors leave the NHS and what can be done to retain them. Since there are multiple groups of junior doctors, and individuals may have different reasons for leaving, we will use a realist synthesis approach that can accommodate complexity. It will adhere to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality standards for realist syntheses (Wong et al., 2014) and methodological guidance (Pawson et al., 2004, 2005; Pawson, 2006a). We will develop an Initial Programme Theory about junior doctor retention based on Advisory Group consultation, substantive theory, and preliminary literature searching. We will test (confirm, refute or refine) the Initial Programme Theory through data from iterative rounds of literature searching, Advisory Group consultation, and a realist logic of analysis. The search strategy and choice of databases will be informed by the initial stages, but are initially proposed as: OVID Medline, Embase, and CENTRAL. We anticipate that terms including ‘junior doctor’, ‘postgraduate doctor’, ‘trainee doctor’, and ‘retention’ will be used, and that we will include UK literature. We will select articles to include in the first round of analysis based on title/abstract and then full-text screening against pre-determined inclusion criteria. We will look across specialties, settings and timepoints to help us to identify the key principles and concepts. After initial coding, the collated insights will be analysed using realist logic, identifying context-mechanism-outcome configurations (CMOCs) that explain why junior doctors leave and what can be done to support retention in different situations and for different people (Pawson, 2006a). We will then develop recommendations and design principles for interventions to improve the retention of junior doctors, for use by employers, leaders and policy makers. We will disseminate the recommendations and design principles widely, using a range of formats, both traditional (e.g. publications, conference presentations) and non-traditional (e.g. infographics, podcasts), to maximise their potential for impact. The project team have extensive experience of the methodology and topic. We have previously worked well together on large HSDR funded projects. We will meet bi-monthly and a subset will meet fortnightly. With input from our Advisory Group, we will develop a range of outputs tailored for specific audiences. To gain impact, we will disseminate these outputs by working with our established network of knowledge users.