Quantitative results
We included 116 residents from seven programs (92.6% response rate). Table 1 presents the characteristics of the participants. The mean scores of the MLQ-5X were: TLS = 3.39 ± 0.72; TrLS = 2.93 ± 0.46; and LfLS = 2.07 ± 0.75 (1–5 range). The mean scores of the DJCS were: global job crafting = 3.50 ± 0.41; job crafting to increase 1) structural resources = 4.35 ± 0.52; 2) social resources = 3.75 ± 0.66; and 3) challenging demands = 3.50 ± 0.61 (1–5 range); and job crafting to diminish hindering demands = 2.59 ± 0.73. Table 2 shows the results of the ANOVAs for the main variables between programs. After Bonferroni correction (p < 0.006), we identified significant differences in the scores for global job crafting to increase social resources and to increase challenging demands. Similarly, we identified significant differences in the scores for a TLS and a TrLS. The Cronbach's α of the MLQ-5X was 0.94. Cronbach's alphas for the subscales of the DJCS ranged from 0.63 to 0.78.
Table 1
Descriptive characteristics of programs and participants
1. Information on participants |
Number of participants (global) Age (mean, standard deviation, range) | 116 Age: 28.59 ± 2.48 (22–36) |
Male (number and percentage) Age (mean, standard deviation, range) | 69 (59.48%) Age: 28.81 ± 2.77 (22–36) |
Female (number and percentage) Age (mean, standard deviation, range) | 47 (40.52%) Age: 28.27 ± 2 (24–34) |
Number and percentage of residents per year of training |
Year 1 | 34 (29.31%) |
Year 2 | 24 (20.69%) |
Year 3 | 32 (27.59%) |
Year 4 | 26 (22.41%) |
2. Information on programs |
Number of programs | 7 |
Average number of residents per training program evaluating their supervisors’ leadership styles (range) | 16.6 (10–21) |
Table 2
Descriptive statistics and one-way Analyses of Variance (ANOVAs) of the relationship between residents’ job crafting and supervisors’ leadership style per program
Variable | Residency program (number of residents per program) | One-way ANOVA |
Global (n = 116) | Prog. 1 (n = 21) | Prog. 2 (n = 20) | Prog. 3 (n = 16) | Prog. 4 (n = 21) | Prog. 5 (n = 16) | Prog. 6 (n = 12) | Prog. 7 (n = 10) | F | p** |
1. Job crafting self-rated by residents on the Dutch job-crafting scale* (means, SD and 95% CI) |
Global | 3.50 ± 0.41 (3.43–3.58) | 3.30 ± 0.32 (3.10–3.45) | 3.32 ± 0.37 (3.15–3.50) | 3.42 ± 0.22 (3.30–3.54) | 3.73 ± 0.19 (3.56–3.90) | 3.47 ± 0.30 (3.31–3.63) | 3.59 ± 0.50 (3.26–3.91) | 3.88 ± 0.53 (3.49–4.26) | 4.98 | 0.0002 |
Increasing structural resources | 4.35 ± 0.52 (4.25–4.45) | 4.25 ± 0.46 (4.04–4.46) | 4.23 ± 0.45 (4.01–4.41) | 4.31 ± 0.33 (4.13–4.49) | 4.53 ± 0.36 (4.36–4.69) | 4.27 ± 0.43 (4.04–4.50) | 4.68 ± 0.28 (4.49–4.86) | 4.22 ± 1.19 (3.36–5.07) | 1.75 | 0.11 |
Increasing social resources | 3.75 ± 0.66 (3.63–3.88) | 3.75 ± 0.60 (3.47–4.02) | 3.35 ± 0.65 (3.04–3.66) | 3.8 ± 0.41 (3.57–4.02) | 4.01 ± 0.57 (3.75–4.28) | 3.75 ± 0.53 (3.46–4.03) | 3.40 ± 0.80 (2.89–3.92) | 4.4 ± 0.65 (3.92–4.87) | 4.63 | 0.0003 |
Decreasing hindering demands | 2.59 ± 0.73 (2.46–2.73) | 2.30 ± 0.56 (2.08–2.59) | 2.59 ± 0.72 (2.25–2.93) | 2.32 ± 0.75 (1.92–2.72) | 2.93 ± 0.84 (2.55–3.31) | 2.57 ± 0.68 (2.20–2.93) | 2.58 ± 0.72 (2.12–3.04) | 2.91 ± 0.68 (2.42–3.40) | 1.95 | 0.07 |
Increasing challenging demands | 3.50 ± 0.61 (3.39–3.61) | 3.08 ± 0.47 (2.87–3.30) | 3.28 ± 0.40 (3.09–3.46) | 3.5 ± 0.53 (3.21–3.78) | 3.61 ± 0.62 (3.33–3.90) | 3.47 ± 0.56 (3.17–3.77) | 3.88 ± 0.76 (3.39–4.37) | 4.18 ± 0.38 (3.90–4.45) | 6.34 | 0.00001 |
2. Supervisors’ leadership style per program rated by residents on the Multifactor Leadership Questionnaire* (means, SD and 95% CI) |
Transformational | 3.39 ± 0.72 (3.26–3.53) | 3.10 ± 0.58 (2.84–3.37) | 2.86 ± 0.60 (2.57–3.14) | 3.01 ± 0.66 (2.65–3.37) | 3.60 ± 0.62 (3.32–3.89) | 3.87 ± 0.61 (3.54–4.20) | 3.71 ± 0.57 (3.35–4.07) | 4.09 ± 0.46 (3.76–4.42) | 9.39 | 0.00001 |
Transactional | 2.93 ± 0.46 (2.85–3.02) | 2.72 ± 0.40 (2.54–2.91) | 2.84 ± 0.45 (2.63–3.05) | 2.75 ± 0.39 (2.54–2.96) | 2.99 ± 0.46 (2.78–3.20) | 3.16 ± 0.44 (2.92–3.40) | 2.93 ± 0.36 (2.70–3.15) | 3.37 ± 0.48 (3.02–3.71) | 3.96 | 0.001 |
Laissez-faire | 2.07 ± 0.75 (1.93–2.21) | 2.04 ± 0.87 (1.64–2.44) | 2.17 ± 0.59 (1.89–2.45) | 1.95 ± 0.70 (1.57–2.33) | 2.29 ± 0.81 (1.92–2.66) | 1.89 ± 0.90 (1.40–2.37) | 1.97 ± 0.63 (1.57–2.38) | 2.07 ± 0.67 (1.59–2.55) | 0.61 | 0.71 |
SD = standard deviation; 95%CI = 95% confidence interval; Prog. = program; Prob. = probability; F = F statistic |
* (Range 1–5) |
Degrees of freedom = 6 (in all cases) |
**Probability was adjusted to p < 0.006 (Bonferroni correction) |
Table 3 presents the linear mixed effects analysis of the relationship between supervisors' leadership styles and global job crafting. A TLS had a positive effect on global job crafting (b = 0.19; 95% CI 0.08–0.32; p = 0.009). In general, the difference between programs regarding the effect of leadership style on job crafting was relatively small (ICC ranged between 0.002 and 0.16). We found no significant relationships between a TrLS and LfLS and global job crafting.
Table 3
Linear mixed effects analysis of the relationship between supervisors' leadership styles and residents' global job crafting
Dependent variable | Fixed effects | Random effects (adjusted per program) | ICC | Goodness of fit |
Transformational style | Transactional style | Laissez-faire style |
b (95% CI) | p | b (95% CI) | p | b (95% CI) | p | Variance (SD, 95% CI) | Residual (SD, 95% CI) | p | R2m | R2C |
Global job crafting | 0.19 (0.08–0.32) | 0.009 | 0.10 (-0.06–0.27) | 0.21 | 0.07 (-0.01–0.17) | 0.10 | 0.01 ± 0.11 (0.000–0.24) | 0.12 ± 0.34 (0.30–0.39) | 0.02 | 10.23% | 0.18 | 0.26 |
b = b estimate; SD = standard deviation; CI = confidence interval; R2m = marginal R squared; R2C = conditional R squared |
ICC = interclass correlation for the random effect (ICC = variance (program) / (variance (program) + variance (residuals))) |
p value: significance level of < 0.05 |
Table 4 shows the linear mixed effects analysis of the relationship between the leadership styles and each job-crafting domain. In general, a TLS was positively related to all job-crafting domains. In three domains (increasing structural and social resources and diminishing hindering demands), the effect was significant (p < 0.05). We found no significant effect between a TrLS and any job-crafting domain. An LfLS had only a significant effect on job crafting to decrease hindering demands (p = 0.0001).
Table 4
Linear mixed effects analysis of the relationship between supervisors' leadership styles and four dimensions of residents' job crafting
Job-crafting dimensions (dependent variables) | Fixed effects | Random effects (adjusted per program) | ICC | Goodness of fit |
Transformational style | Transactional style | Laissez-faire style |
b (95% CI) | p | b (95% CI) | p | b (95% CI) | p | Variance (SD, 95% CI) | Residual (SD, 95% CI) | p | R2m | R2C |
Increasing structural resources | 0.16 (0.04–0.29) | 0.009 | 0.06 (-0.12–0.24) | 0.50 | − 0.10 (-0.20–0.005) | 0.06 | 0.01 ± 0.11 (0.000–0.23) | 0.14 ± 0.37 (0.32–0.43) | 0.04 | 8.22% | 0.15 | 0.22 |
Increasing social resources | 0.20 (0.005–0.40) | 0.04 | 0.19 (-0.09–0.48) | 0.18 | − 0.05 (-0.22–0.11) | 0.51 | 0.05 ± 0.22 (0.03–0.45) | 0.35 ± 0.59 (0.51–0.67) | 0.007 | 12.88% | 0.09 | 0.21 |
Decreasing hindering demands | 0.27 (0.06–0.47) | 0.01 | − 0.02 (-0.34–0.29) | 0.88 | 0.37 (0.19–0.56) | 0.0001 | 0.001 ± 0.03 (0.000–0.23) | 0.46 ± 0.68 (0.59–0.76) | 0.39 | 0.21% | 0.16 | 0.16 |
Increasing challenging demands | 0.15 (-0.02–0.34) | 0.09 | 0.22 (-0.02–0.49) | 0.08 | 0.06 (-0.08–0.21) | 0.39 | 0.05 (0.04–0.45) | 0.29 ± 0.53 (0.46–0.61) | 0.004 | 15.79% | 0.09 | 0.23 |
b = b estimate; SD = standard deviation; CI = confidence interval; R2m = marginal R squared; R2C = conditional R squared |
ICC = interclass correlation for the random effect (ICC = variance (program) / (variance (program) + variance (residuals))) |
p value: significance level of < 0.05 |
The marginal R2m was relatively low in all models, suggesting that factors other than supervisors’ leadership styles may have influenced residents’ job crafting. The conditional R2c was larger in all models, indicating that the effect of the program, albeit small, was important (Tables 3 and 4).
Qualitative results: Exploring the associations between supervisors’ leadership style and residents’ job crafting
Six participants were female (42.8%). The distribution of participants by year of training was as follows: Year 1 (n = 4), year 2 (n = 3), year 3 (n = 3), and year 4 (n = 4). Three predominant themes emerged from the interviews. Table 5 gives an overview of representative quotations.
Table 5
Quotes from the interviews illustrating the main themes
Supervisors’ leadership style | Theme 1: Supervisors’ leadership style influences the atmosphere for training | Theme 2: Supervisors’ leadership style influences the availability of job resources | Theme 3: Supervisors’ leadership style serves as role model for how to handle the environment |
Transformational | These supervisors, undoubtedly, create a better work environment. The hardest part of residency is not the workload, fasting, or the lack of sleep, but having a good relationship with the supervisors and peers. A quiet environment makes it easier for residents to work hard. (Interview #12: 4th -year male resident) | This type of leader offers the resident opportunities to be autonomous -within the framework of patient safety- to identify what [the resident] is doing well, and to have confidence ... They [the supervisors] tell him/her: "I want to operate on this patient with you,” or “you are going to operate on this patient." These are ways to strengthen autonomy, which causes the resident to fight his/her own demons [fears]. (Interview #3: 3rd -year male resident) | All of us [residents] have difficult times during residency. If you have a role model, a supervisor with whom to share the anguish, that's good, that can help you to stay in the program. You admire some supervisors, not only because of their surgical capabilities, but also because of their integrity, because they are good human beings ... Sometimes you have big problems, but they can help you to see them smaller. These models make you see the problems from other angles to solve them. (Interview #1: 2nd -year female resident) |
"Receiving positive influences makes you feel more motivated about what you do ... if you are in a positive atmosphere you will find much more enjoyment and love for what you do." (Interview #8: 4th-year male resident) | "When you are in contact with supervisors who provide good feedback and assessment, my mistakes can improve. Otherwise, the resident is left without knowing if he/she did things right or wrong." (Interview #4: 3rd -year female resident) | When we [residents] find a person who is charismatic, who salutes, who is decent, who has manners, who gets along well with all people, and who has good results and relationships with patients, we identify with that type of leader. A leader is someone who not only knows how to manage people, but also shows other people how to solve problems. Almost always, this type of leader has the solution to problems, easily and without collateral results. (Interview #14: 1st -year male resident) |
"In an environment of trust the resident has a better development, while he/she loses his/her fears of being judged by his/her opinion and decisions ... You feel a safe environment where you will not be judged negatively." (Interview #8: 4th -year male resident) | "This supervisor supports good decisions [by residents], or appropriately corrects wrong decisions. This generates a good, safe, and positive environment, which leads to more calmness for the resident. One works better and has better results." (Interview #9: 3rd -year male resident) | "A resident who has a good model -someone who inspires him/her more, [expresses] confidence and encourages his/her improvement- is a better example than the one who is just waiting for an excuse to punish." (Interview #12: 4th -year male resident) |
Transactional | When leadership is based on punishment, the academic and work environments are hostile. Residents’ behavior is based on fear. This is inappropriate practice [professional practice] for the patient. The resident is thinking how to avoid errors, to prevent a negative response from the supervisor. This generates greater stress for the resident ... The resident acts defensively and not proactively in the patient’s favor. (Interview #4: 3rd -year female resident) | "These supervisors are focused on the error and do not give feedback to the resident ... so the resident keeps making mistakes. That is not a good way to teach." (Interview #6: 4th -year male resident) | "They are people [supervisors] who were in a residency program in which their supervisors did the same [punishment]. They think that if there is no punishment, or a threat, residents will not perform well." (Interview #13: 4th -year female resident) |
"Fear causes a lack of control over situations leading to wrong decisions. When one is afraid, one does not work well. That kind of supervisor generates fear." (Interview #9: 3rd -year male resident) | When the resident makes a mistake, he/she loses his/her reward, that is: not getting to operate on patients. Then, he/she avoids mistakes, because he/she will lose his/her reward. There is nothing more serious in education than to be afraid of making mistakes, because that is not the way a human being learns. If I make a mistake, they [supervisors] take away my opportunity to be in surgery! (Interview #3: 3rd -year male resident) | A resident who faces punishment and reward models is uneasy about and dissatisfied with training. Some resilient people may not leave the program (perhaps the majority of residents), but there are others who do not endure that ... They do not sacrifice their calmness and happiness and they leave the program. (Interview #8: 4th -year male resident) |
"If a person is repeatedly punished and does not receive an adequate way to control the environment [from supervisors], he/she can fall into eternal punishment ... creating a poor work environment...” (Interview #14: 1st -year male resident) | "Supervisors know that the biggest punishment is to not allow residents to operate on patients, which discourages and demotivates them … Then, a resident in an environment with a high workload and stress will not have good results." (Interview #12: 4th -year male resident) | I do not want to be like that person [the supervisor]. I do not want that life for me. If you see that your supervisor is rude, bad-tempered, someone who is not able to control his/her anger (such people almost always have personal problems, divorces, and do not spend enough time at home), the resident may say: "this is not the life that I want in the future!" So, the resident leaves the program. (Interview #3: 3rd -year male resident) |
Laissez-faire | "These supervisors do not generate fear, but you do not feel supported, which affects the control of the environment." (Interview #9: 3rd -year male resident) | "Those supervisors leave the resident alone with the problems ... They do not respond when they are needed." (Interview #1: 2nd -year female resident) | "They are not a good model ... If I do not see a desire for leadership in the supervisor, he/she will not be a role model. [Their supervision] does not generate anything in me." (Interview #1: 2nd -year female resident) |
"Passivity creates a boring work environment." (Interview #2: 1st -year female resident) | Residents cannot control the environment well because the supervisor simply leaves the resident alone, does not supervise anything that the resident is doing ... does not teach him/her anything. He/she [the supervisor] does not care if the resident is doing things right or wrong. He/she simply leaves the resident to his own devices. (Interview #13: 4th -year female resident) | If you have a disinterested, a passive supervisor who does the minimum required to fulfill, you are getting a bad model. Very little profit is taken from them, because they do not commit, do not make decisions and do not take appropriate care of situations ... They simply expend the least effort possible. (Interview #12: 4th -year male resident) |
Many supervisors are passive leaders, many of them spend time with residents because it is their obligation. Although they are part of a surgical team, they are not real supervisors, they are not interested [in residents’ education] ... They are indolent and indifferent to the resident ..., so there is no real connection between supervisor and resident ... It is not an enriching environment for learning. (Interview #11: 2nd -year female resident) | These supervisors do not ask me anything [clinical or academic issues], they do not contribute to my training, they are simply focused on their administrative duties ... this makes me feel that I'm wasting my time. They do not demand anything from me. (Interview #5: 1st -year female resident) | "That supervisor is not a good role model because he/she is an indecisive person, someone who confuses." (Interview #14: 1st -year male resident) |
Theme 1: Supervisors’ leadership style influences the atmosphere for training in positive or negative ways
Residents mentioned that supervisors who had a TLS could promote a positive atmosphere for training and showed high standards of patient care. The personal strengths they attributed to such supervisors were altruism, integrity, resilience, and trustworthiness. Residents valued this atmosphere because it made them feel free to discuss their fears and expectations of training, strengthening both their performance (e.g., decision-making and problem-solving skills) and readiness for practice. In residents’ view, these supervisors stimulated them to stay in the program and pursue their training.
Conversely, residents characterized supervisors who had a TrLS as people who actively searched for errors, and were punitive and authoritative, which did not encourage them to take the lead in their own training on the job. In most cases, these supervisors created a hostile atmosphere for training where residents experienced fear and mistreatment, leading to defensive behaviors to hide errors and avoid punishment, and to more intentions to leave training.
Finally, residents mentioned that supervisors who had an LfLS showed a lack of commitment to patient care and residents’ education and were perceived to help create a negative atmosphere in the workplace. Moreover, they contributed to more demands for the resident (i.e., more workload), resulting in unsafe care for patients. At the same time, however, the rare presence of these supervisors in the workplace encouraged residents to take more care of patients and to deal with workload and pressure.
Theme 2: Supervisors’ leadership style influences the availability of job resources
Residents mentioned that supervisors who had a TLS offered the resident more job resources and challenges in the workplace (e.g., in the form of support, teaching, and feedback). Supervisors who had a TrLS and LfLS, by contrast, provided fewer of these resources and challenges, while creating more hindering demands (e.g., workload and pressure). For instance, supervisors who had a TrLS gave poor feedback and instruction and frequently punished residents by limiting opportunities to participate in surgical care and to take on new challenges (such as the opportunity to operate complex patients). In residents’ views, these negative aspects of training led to psychological distress, a lack of autonomy, and more intentions to leave training.
Theme 3: Supervisors’ leadership style serves as role model for how to handle the demands in the workplace
According to residents, supervisors with a TLS were positive role models. More specifically, these supervisors were capable of handling the work environment and finding solutions to difficult situations effectively, for instance when surgical complications or conflicts arose at work. Supervisors with a TrLS or an LfLS, on the other hand, were perceived as negative role models, because they created more demands for the resident (in the form of conflicts, ambiguity), while wielding ineffective strategies to solve difficult situations.