Factors Contributing to Stress and Well-Being Among Trainee Psychiatrists in Victoria, Australia

Abstract

Doctors in training experience stress, as they balance the demands of working and studying at the same time. As evidenced by reports of suicides among trainee doctors, it is clear that the level of stress they experience is dangerously high. Long working hours, which can lead to exhaustion, burnout, and time taken away from meaningful activities and relationships outside of work, are a large contributor to trainee stress and increase the likelihood of mental illness and suicidal ideation. For psychiatry trainees, this workload burden is also compounded by a high emotional burden associated with the nature of their work, including patient suicides, aggression, and threats. This study sought to investigate the factors that contribute to the stress and well-being of psychiatry trainees, through in-depth interviews analyzed via qualitative, template analysis. The main sources of stress identified were workload, aspects related to the psychiatry training program, and workplace-based aggression. Supervision, external supports such as family and health professionals, and distraction or “switching off” were the main sources of well-being support. Overall, this study highlighted the importance of structural factors in the workplace and training program in psychiatry trainee stress and well-being levels. Workload and training commitments limited the amount of time trainees could devote to well-being-related activities, despite their awareness of these. This study contributes useful insights into how we can better look after the mental health and well-being of psychiatry trainees, as future leaders of our mental health system.

Appendix: Interview Schedule

Basic demographic information
Age	________
Gender	________
Year (e.g., 1–5) of psychiatry training	________
Year (chronological) of graduation in medicine	________
Do you have a partner (yes/no)?	________
Do you have children (yes/no) and, if so, how many?	________

What key RANZCP exams or other assessments (e.g., psychotherapy case) have you successfully completed to date?

___________________________________________________________________________

___________________________________________________________________________

What key RANZCP exams or other assessments (e.g., psychotherapy case) remain to be completed?

______________________________________________________________________________

______________________________________________________________________________

Prior non-medical qualifications or employment outside medicine.

______________________________________________________________________________

______________________________________________________________________________

Prior completion of training in another medical specialty.

_______________________________________

_______________________________________

Note to interviewer: Please ensure that trainees elaborate on the reasons for their responses and do not answer simply in a “yes-no” manner. If a trainee does not spontaneously do so, please follow up each question with “please elaborate” or “please explain.”

Work Demands

Work-related stress, engagement, and psychological capital

• The term “engagement” may be used to describe employees who are energetic, dedicated, and absorbed in their work.

  • Would you consider yourself to be well engaged in your work and training at present?

  • How well do you believe you are performing your job at present?

• Have you ever experienced work-related stress? What is the source of this stress?

• Has work-related stress ever impacted adversely on your performance or have the potential to do so?

• Self-beliefs such as self-efficacy, hope, optimism and resilience may be helpful in countering the effects of work-related stress.

  • Do you make use of any such beliefs to manage the demands of work and training or cope with any work-related stress you experience? [Clarify which belief(s) in particular].

  • How else do you manage work-related stress?

• Have you ever contemplated leaving the psychiatry training program because of the demands associated with it?

General clinical challenges

• What aspects of your clinical work in psychiatry do you find most challenging?

• Do you find these aspects of your clinical work challenging in a positive sense or are they a source of work-related stress? If they are stressful, why is this so? If not, what factors help to mitigate the stress?

• Are you well supported in managing aspects of your clinical work by clinical supervisors and the service more broadly?

Working Hours

Clinical workload

• Is your clinical workload in your current and/or prior rotations reasonable and manageable?

• Have inadequate staffing levels in your current or prior workplaces contributed to an excessive clinical workload?

• Could your current or prior placements have been better designed to make your workload more manageable?

• Have you been given adequate opportunities to redesign your job yourself (e.g., through task selection or job content renegotiation) to make your workload more manageable? If not, do you think such opportunities would be helpful?

Mental Health Tribunal

• Were you working in psychiatry prior to the change in the Mental Health Act (MHA) in 2014?

• Has the change to a new MHA in 2014 impacted on your workload as a registrar?

• Do you find the volume of work needed to prepare for Mental Health Tribunal hearings excessive or the process of presenting at MHT hearings stressful? Is this more so than under the previous MHA (if applicable)?

• Do you think there is a role for aspects of your job being redesigned (by your employer or yourself) so that you can better meet the demands of preparing patients for MHT hearings?

Job Control

Factors intrinsic to the College Training Program

• What are the positive aspects of the College Training Program and the associated examination process?

• What aspects of the College training or examinations are most stressful?

• Has failure to pass examinations or otherwise meet College training requirements ever given rise to a sense of (or actual) job insecurity?

• How can the College training program be improved?

Work-training interface and human resources issues

• Do training and working requirements ever conflict? If so, do you see this conflict originating within the training program (e.g., unreasonable training demands or difficult exams) or within the health service (e.g., inadequate facilitation of training)?

• What changes could be made by your employer or yourself to increase your sense of control in relation to training activities within the workplace?

• Has the on call roster ever been a source of work-related stress?

• Have leave arrangements ever been a source of work-related stress?

• Have any requests in relation to job flexibility, such as working part time or accessing specific rotations, been easily met?

Social Support at Work

Team dynamics

• Would you identify team dynamics in your immediate workplace as generally good, poor or somewhere in between?

• Have poor team dynamics ever been a source of work-related stress? If so:

  • What was the nature of these poor team dynamics?

  • How did they impact adversely on you?

  • How did they impact adversely on other team members?

  • What did you do to address the problem?

Clinical supervision

• Do you believe that current formal supervision requirements as mandated by the RANZCP are adequate in meeting trainee needs or should they be changed in any way?

• Have you found RANZCP supervision requirements to be implemented well in practice within the clinical service?

• What type of support do you seek from clinical supervisors and have they generally been supportive in practice?

• Can you provide an example of a positive supervision experience you have had and explain what made it positive?

• Is there any particularly negative supervision experience that comes to mind? Why was it so negative and what could have been done to improve it?

Relationship with other medical disciplines

• As a psychiatry trainee how well do you get along with doctors from other disciplines within the organization at a personal level?

• Is psychiatry (or is practitioners) ever marginalized or stigmatized by other medical disciplines within the organization? Have you ever been personally affected by this?

• Is there anything that the clinical service can do to improve the image of psychiatry and reduce stigmatization within the organization?

• Is there anything more that the RANZCP should be doing to improve the image of psychiatry and psychiatry training more broadly?

Support within the workplace

• Please indicate whether you find each of the following groups supportive or otherwise and describe the sort of support you might turn to each for:

  • Health service managers (including senior medical administrators).

  • Peers (trainees and other junior medical staff).

  • Other multidisciplinary team members.

• Do you look for support outside the workplace (e.g., from family and friends) to complement support received within the workplace or to compensate for a lack of such support?

• Are you aware of resources you can access for assistance if you become emotionally distressed as a result of your work and training in psychiatry?

  • If so, please identify these resources.

  • How comfortable would you feel to access these resources at a time of need and why?

  • Can you identify any factors that would increase your confidence in accessing such services if required?

Work-Family Conflict

Support from family and friends

• What sort of non-professional supports outside the workplace do you have available to help you with your training and clinical work?

• Do you believe that your clinical work or training requirements (or both) impact adversely on other people close to you, such as family or friends?

• Do difficulties at home ever impact on your role as a psychiatry trainee?

• Conversely, do you find a source of support in your family and friends in relation to your clinical work and/or training?

• Overall, do you feel that you are able to achieve a reasonable work-life balance as a psychiatry trainee?

Role Changes

Orientation and handover

• Would you characterize the quality of the orientation provided at the outset of each rotation as good, average or poor?

• Which areas have been covered well and which poorly during orientation?

• Would you characterize the quality of the handover received at the outset of each rotation as good, average or poor?

• Has the quality of orientation and/or handover at the outset of a rotation ever impacted on your subsequent sense of control over your work during that rotation?

• Do you have any recommendations regarding how orientation and/or handover can be improved for future cohorts of registrars?

Proficiency in dealing with physical health problems

• How much experience do you have of working in other areas of medicine prior to entering psychiatry training?

• Have you been able to maintain your expertise in dealing with patients’ physical health problems or do you feel that your skills in this regard are deteriorating over time?

• Are medically compromised patients ever a source of work-related stress?

• What could be done to improve you skills and confidence in managing your patients’ medical problems?

Antisocial Behaviors

Workplace-based violence, harassment, or bullying

• Have you ever witnessed or been subjected to workplace-based violence, harassment or bullying? If so, please describe the circumstances involved.

• How did this experience impact on you both within and outside the workplace?

• If you were the one subjected to these behaviors, did your experience impact adversely on others within the workplace (e.g., other trainees) or outside the workplace (e.g., your family)?

• Did you draw on any positive self-beliefs such as self-efficacy, hope, optimism or resilience to help you cope with this experience? [Clarify which belief(s) in particular].

• Did your employer (and/or the RANZCP) do enough to support you after this experience? What was most helpful about the support provided? How could it be improved?

• Did you draw upon any non-work-related resources to cope with this experience, such as family and friends or a professional counsellor?