Table 1 Summary of the CMOcs (programme theory)

 CMOc 1: Underdeveloped workforce planning

In a workplace in which basic support structures to enable doctors to do their job are not in place (C), doctors may feel they must make up for the deficiencies of the organisation for patients and colleagues (M). This may contribute to a toxic working culture in which overwork and its negative consequences are normalised (O).

 CMOc 2: Normalisation of high workload

When high workload and its negative consequences (e.g. distress, burnout) are normalised (C), overworked or sick doctors may feel they are letting down their colleagues and patients (M). This can contribute to presenteeism (O) and associated negative consequences on mental health (O1) and workforce retention (O2).

 CMOc 3: Loss of autonomy

When doctors experience lack of autonomy over their work (C1), and some aspects of their work as less meaningful (C2), they may feel dissatisfied with their job (e.g. because they are unable to do the job they were trained for) (M). This can make doctors more vulnerable to stress and mental ill-health, irrespective of workload (O).

 CMOc 4: Stigma towards vulnerability

In a professional culture where mental ill-health and vulnerability may be seen as unprofessional (C), doctors (and medical students) may feel ashamed (M1) or afraid (M2) of not living up to their professional identity if they experience mental ill-health (or other difficulties at work). This can lead doctors (and medical students) to adopt strategies which involve hiding their difficulties from themselves and colleagues (O).

 CMOc 5: Hiding vulnerability

Where there is mental health support available for doctors (C1), doctors, who understand the system and that confidentiality is difficult to achieve (C2), may fear that seeking support could jeopardise their career (M) and so they may hide their distress rather than seek support (O).

 CMOc 6: Isolation

When doctors work in physical and emotional isolation (C), they are likely to feel less supported by their colleagues and/or their employing organisation (M1) and/or mistrust of these groups (M2). This can make doctors more vulnerable to work-related pressure and mental ill-health (O).

 CMOc 7: Positive and meaningful workplace relations

Positive and meaningful workplace relations (C) can foster a sense of belonging between colleagues and towards the medical profession (M). This can lead to an increased capacity to work under pressure (O)

 CMOc 8: Functional working groups

Working in functional groups (C) can make doctors feel more supported (M1) and more at ease with vulnerability (M2). This can normalise vulnerability (O1) and reduce the stigma around mental ill-health (O2)

 CMOc 9: Balancing quality and quantity of time at work

When doctors (for different reasons) have less connectedness and meaning at work (C), they may feel they can only find fulfilment outside work (M1), making it less likely that their condition will improve (O).

 CMOc 10: Limits of groups

Sick doctors (and medical students) with particularly delicate circumstances (C) may not feel safe to share their problems (M1) and/or may not identify with the other group members (M2). This can result in a dysfunctional group (O1) and intensification of mental ill-health in doctors (O2).

 CMOc 11: ‘Organic’ spaces to connect

If there are protected times and psychologically safe spaces for students/doctors to congregate within the confines of the work environment (C), students/doctors are likely to bond over whatever is most important to them at that time (M). This may improve connectedness (O).

 CMOc 12: Recognising both positive and negative performance

Where supervision and feedback recognise both positive and negative performance and promote doctors’ (and students’) learning from both of these (C), doctors (and students) may feel more fairly treated (M1) and more inclined to value their colleagues and employing organisation (M2), potentially leading to more connectedness and engagement at work (O1), and a more supportive work culture (O2).

 CMOc 13: Balancing prevention of metal ill-health with promotion of wellbeing

In a work environment that actively demonstrates the importance of the balance between health and wellbeing with fighting stress and mental ill-health (C), doctors (and students) are more likely to feel that caring about their own wellbeing is legitimate (M1) and less afraid to acknowledge vulnerability (M2). This can contribute to a de-stigmatisation of mental ill-health and vulnerability (O).

 CMOc 14: Acknowledging the positive and negative aspects of the profession

Where both the positive and negative aspects of a medical career are recognised (C), doctors (and medical students) may feel less inadequate and helpless when they or their colleagues experience stress or mental ill-health (M). This may lead to increased capacity to deal with work pressure (O1) and to recognition and acceptance of vulnerability (O2).

 CMOc 15: Timely support

Timely support when doctors (and students) are particularly vulnerable (e.g. after a suicide attempt, death of a colleague, addiction) (C) may represent their only source of hope (M) and reduce the intensity of mental ill-health and its related outcomes, including suicide (O).

 CMOc 16: Endorsement

Doctors are less likely to engage with an intervention (O) if it is not endorsed by the employing organisation and senior leadership (C) because they may then lack trust in it (M1) and may also feel frustrated (M2) if they cannot access it due to work constraints.

 CMOc 17: Expertise

If those delivering interventions do not have specific training to address the needs of sick doctors (C), the recipients may be less likely to trust the intervention (M) and the intervention may be ineffective (O1) and/or harmful (O2) or not accessed at all (O3).

 CMOc 18: Engagement

If doctors (and students) are involved in the development and implementation of interventions (C), the recipients are more likely to trust (M1) and feel ownership (M2) of the intervention. As a result, it is more likely to be used (O1) and to be effective (O2).

 CMOc 19: Evaluation

If the outcomes of interventions and the wellbeing of the workforce are regularly reviewed and monitored (C1), and commitment to act upon the outcome of these regular review exercises is shown (C2, and CMOc 16), then doctors may feel more supported (M) and engage with efforts to tailor these interventions (O1). This may also lead to greater awareness about vulnerability and wellbeing in the workplace (O2).