Transitioning to residency: a qualitative study exploring residents’ perspectives on strategies for adapting to residency | BMC Medical Education

Our study showed that TTR involves a dynamic social interplay between residents and other healthcare professionals [12, 13]. Through analysis of qualitative exploratory in-depth interviews, we found that residents used five individual strategies to adapt to their new role: observing, asking questions, experimenting, establishing social relationships, and seeking information. These strategies enabled residents learn how to perform their tasks, behave appropriately, and integrate into the healthcare team. Additionally, residents encountered various organizational strategies employed by healthcare professionals to facilitate their transition, which we identified through the lens of Organizational Socialization theory, using its six dichotomous tactics: collective–individual, formal–informal, sequential–random, fixed–variable, serial–disjunctive, investiture–divestiture.

A key contribution of this study lies in revealing how organizational strategies employed by other healthcare professionals directly impact residents’ adaptation efforts. This interaction between organizational and individual strategies has not been explicitly addressed in previous research and extends the theory of organizational socialization by demonstrating how these strategies intersect [22, 23]. Moreover, our study highlights a previously underexplored complexity: residents differed in their perceptions of whether a specific organizational strategy facilitated or hindered their transition. This divergence underscores the importance of considering individual preferences in the balance between support and autonomy during residency training, as some residents benefit from greater independence, while others require more structured guidance.

Our findings indicate that individual strategies not only support residents’ socialization into the health care team [45, 46], but also enhance their role-based performance by helping them acquire practical knowledge and skills. Similar findings were observed in undergraduate medical students, where strategies like seeking information and feedback, negotiating tasks and building relationships helped students’ navigate their roles [24, 28]. Moreover, we showed that organizational strategies were enacted at both interpersonal and system levels. This aligns with previous research on nursing graduates and medical students, which emphasized the influence of supportive of senior staff and a safe learning environment [24, 25].

Additionally, the tension between support and autonomy was evident in residents’ reflections on role models. Some residents felt that absence of a role model allowed them to exercise greater autonomy, while others found it hindered their learning. This raises important questions about whether residents were advocating for less role modelling (i.e. more independency) or merely adapting to a suboptimal situation. Program directors, however, did not consider the absence of a role model as a viable strategy [19]. In fact, in the United States (and likely in other contexts), the absence of role models is legally impermissible in educational settings, making it an unrealistic approach. While other studies have not addressed the absence of role models as a deliberate strategy, prior research highlights the tension between support and autonomy in residency training [2, 47, 48]. Often, residents’ responsibilities do not align with their desired levels of autonomy, leading to perceptions that their duties are either too excessive or too limited [2, 47, 48]. This reflects the broader challenge of balancing educational support with independence. Supervisors, nurses and peers can consciously apply role modelling strategies to better balance residents’ needs for autonomy and support. These insights can help both residents and healthcare professionals adjust their strategies to optimize transitions, while considering individual preferences and needs [19].

Practical implications

Three practical implications logically follow from the results of our study. First, we recommend residency program directors incorporate information about individual adaptation strategies into onboarding programs for residents. So far, these programs mainly focus on clinical aspects of residents’ new role or reflective practice during transition periods through coaching or visual arts-based activities [4,5,6,7]. Second, knowledge and awareness of organizational strategies can inform the design of onboarding programs for residents. Decisions have to be made, for example, on whether the introduction period will be formal or informal, whether the role of role models or mentors will be made explicit or not and whether the introduction period will be organized within a fixed or a variable time frame. Third, at interpersonal level, we recommend to let the entire health care team play a role in onboarding programs for residents. From the literature, we already know that nurses often take an important informal role in the onboarding of new residents [20]. To empower the entire healthcare team to play a role in residents’ onboarding, we recommend that residency program directors develop interprofessional faculty development initiatives for supervisors as well as nurses, same-year and senior residents and administrative staff [49]. These initiatives should not only respond to the individual needs of residents, but also equip healthcare professionals with the skills to assess and adapt to residents’ preferences for autonomous versus guided learning. Given the variation in how residents prefer to be supported during transitions, developing the ability to read and respond to these preferences is crucial for fostering effective onboarding and ongoing development.

Strengths, limitations and future research

A strength of our study is the inclusion of residents from multiple specialties, providing diverse perspectives on how social interactions influence TTR. Additionally, the multidisciplinary nature of our research group enriched the analysis by incorporating various professional insights, which contributed to a more comprehensive understanding of the socialization processes during residency.

Residents’ socialization processes involve interactions with many other healthcare professionals, therefore future research should include (perceptions of) the entire interprofessional environment surrounding the resident, including supervisors, nurses, advanced practice practitioners, senior residents and peers. To improve TTR and promote collaboration with other healthcare professionals, it is essential that all health care professionals acquire knowledge of one another’s work contexts and activities [50]. A possible lens to explore the perspectives of different types of healthcare professionals and help them understand each other’s values and practices is using social capital theory and social network analysis, which allows for in-depth identification of interpersonal relationships and understanding of how these may influence TTR [51, 52]. Residents can, for example, be asked to describe challenging situations they experienced and how they utilized their social networks to navigate these challenges. This analysis will help identify key relationships that facilitate or hinder residents’ adaptation and will provide a deeper understanding of how interprofessional teams can support each other during transitions.

Furthermore, our study noted peer-to-peer interactions as a potentially valuable component of residents’ TTR, as reflected in Table 4, excerpt 6. However, the influence of these interactions on the choice of organizational socialization (OS) strategies was not a clear pattern in our findings. Future research could investigate how peer-to-peer interactions shape residents’ OS strategies and adaptation processes. For instance, longitudinal studies could observe residents over time to capture how interactions with more experienced peers influence their coping strategies, professional growth, and integration into the clinical environment. Such studies could also explore whether intentional peer mentoring or peer-led initiatives positively impact the socialization process, offering practical recommendations for residency programs. Expanding on these directions, future studies should be broadened across GME systems and explore the impact of targeted interventions, such as structured mentorship programs or workshops that emphasize interprofessional collaboration. This would further our understanding of the mechanisms underpinning successful transitions and promote evidence-based practices to optimize TTR across varying contexts.

Our study also has some limitations. While it is reasonable to have interviewed 16 residents from 10 programs across two hospitals, it is important to acknowledge that such a convenience sample could miss perspectives from other residents in the same programs. We cannot determine whether the reactions of those interviewed are representative of all residents in these programs. However, our aim with a qualitative research design was not to generalize from a random sample, as in quantitative research, but to identify local patterns within the data. Future quantitative research could investigate the extent to which the strategies and adjustments of newcomer residents observed in this study are generalizable in a larger, random sample. Additionally, the interview script broadly addressed how second-year residents reflected upon their experiences during their first year, allowing us to ask deeper questions that responded to their answers. However, this retrospective approach relied on recall, which has inherent drawbacks, including a decline in the quality of gathered data and the risk of participants not consistently retaining detailed information about past events [53]. While this limitation might affect the data, a potential advantage is that reflecting on experiences after a longer time span allows for deeper examination and critical analysis of those events. Additionally, during the template analysis we decided to apply the theory of Organizational Socialization (OS), which may have reduced the depth of information gathered. However, this can also be considered a strength since OS theory contributed to a more in-depth understanding of the socialization strategies used in TTR [42]. Moreover, using existing theory as a lens to inform data analysis is common in qualitative research based on a constructivist paradigm [30].