Causes and impact of stress among Junior Medical Officers working in tertiary care settings: a systematic review protocol Jennifer Costi, Dip T (Sec), MEd Studs, Grad Cert Ed 1,3 Alan Pearson, AM, RN, ONC, Dip N Ed, DANS, MSc, PhD, FCN (NSW), FAAG, FRCN 2,3 1. Candidate, Master of Clinical Science, School of Translational Health Science, Faculty of Health Sciences, University of Adelaide, South Australia 2. Professor, School of Translational Health Science, Faculty of Health Sciences, University of Adelaide, South Australia 3. The Joanna Briggs Institute Review question/objective Corresponding author Jennifer Costi jennifer.costi@adelaide.edu.au What are the causes of stress and what is their impact on individual work performance among Junior Medical Officers working in tertiary care settings? Background The initial experiences in full time work as a medical practitioner have often been described as stressful. In Australia, although the Junior Medical Officer may have met the requirements for the MBBS degree or similar by completing their undergraduate or graduate program at a university, they still have to obtain employment at a teaching hospital in an accredited training program in order to satisfactorily complete an intern year. During the first year of employment, the Junior Medical Officer is often and usually referred to as an intern. During this intern year, the Junior Medical Officer is granted provisional registration by the Australian Health Practitioner Registration Authority (AHPRA). At the end of that year, the intern usually progresses to full registration when details of satisfactory completion of the intern have been supplied by the employing hospital to AHPRA. Criteria for satisfactory completion of the intern year include 48 weeks of satisfactory service and a determination by the supervising Consultant of satisfactory completion of three core terms of 10 weeks duration. The core terms are in the broad subject domains of medicine, surgery and emergency. The first year of employment as a Junior Medical Officer has a formal component of assessment included to meet the requirements of AHPRA. Lack of success experienced during this year will have 10.11124/jbisrir-2014-1284 Page 89
direct ramifications on employment opportunities in the subsequent year. These requirements are layered onto the first year of full-time professional work. Firth-Cozens described levels of stress in Junior House Officers in the UK as higher than other reported occupational groups and estimates the prevalence of emotional disturbance at 50%, with 28% of the subjects showing evidence of depression. 1 Willcock et al., describe junior medical staff as having high rates of psychological and psychiatric morbidity. 2 Brown and Arnold suggest that the need to debrief and reflect on the stresses that confront them is important and also looks at the Australian Curriculum Framework for Junior doctors for structures to provide proper feedback, supervision and caring for our next generation of doctors. 3(p501) Combined with this is an understanding expressed by Jenkins in the Medical Journal of Australia (MJA) that doctors may have susceptible personalities that cause them to become stressed or psychiatrically unwell. 4 He further suggests that it is imperative that the stresses of the job and the workplace are recognized and that efforts are made to reduce them. Markwell and Wainer in exploring the need for a healthy medical work force for the future, look at how this relates to junior medical officers minimizing their own health issues and failing to recognize, acknowledge or act on the early warning signs of illness. 5(p441) The pressure to perform to a satisfactory standard at the very least is often done at the expense of self-care. The Australian Medical Association (AMA) too through their Doctors in Training group (2006) has made recommendations regarding debriefing, support and stress management. At the extreme end of stress and distress, Tyssen et al., found that suicidal ideation was high in medical students and young doctors. 6 While suicide attempts were lower by comparison, Tyssen et al., concluded that clinical implications should address coping with stress and the provision of mental health services for young doctors. Reviews related to these issues have been conducted by Shapiro et al., in Stress Management in Medical Education: A Review of the Literature. 7 Another review by Tyssen and Vaglum looked at the previous 20 years of data. 8 While there exists a body of knowledge about stress and related morbidities in relation to Junior Medical Officers, the drawing together and review of this data has not been undertaken for some years. It is obvious that as time progresses, certain stressors such as working hours will be ameliorated by the introduction of reduced working hours under industrial awards and legislation. Other stressors may be exacerbated by the expectations of colleges for Junior Medical Officers to have research experience prior to, or concurrent with, application for admission to the college program. Other stressors may not be apparent, such as changes in the IT environment which may need further and hidden effort. Combined with this, the domestic and professional dynamic has evolved over the last 35 years since Firth-Cozens first wrote about emotional stress in Junior House Officers. There are also stressors that are specific to subsets of the cohort, such as communication issues for International Medical Graduates (IMGs) who also have to travel the path from limited to full registration under the AHPRA guidelines. 9 10.11124/jbisrir-2014-1284 Page 90
Keywords Stress; distress; work performance Inclusion criteria Types of participants This review will consider studies that include Junior Medical Officers in their first three years of postgraduate employment who have not yet been accepted into a vocational training program. Phenomena of interest Stress among Junior Medical Officers Types of outcomes This review will consider studies that include one or more of the following outcome measures: levels of stress (as measured by any validated standardized stress scale such as the Perceived Stress Scale of the Psycho-social Stress Scale); measures of individual work performance; sickness and absence rates. Studies that do not report on these measurable outcomes may be included if they analyze self-reported accounts of perceived stress. Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case-control studies and analytical cross sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published in a language other than English will not be included. Studies published between 1985 to 2013 will be considered for inclusion in this review. Research into this topic only emerged in the mid 1980s and a general search of the literature did not identify any studies prior to 1985. The databases to be searched include: PubMed and EMBASE The search for unpublished studies will include: Dissertation abstracts international and MEDNAR 10.11124/jbisrir-2014-1284 Page 91
Initial keywords to be used will be: Junior Medical Officer, medical staff, house officer, medical interns, medical residents, prevocational doctor.stress, mental stress, anxiety, distress, tertiary care Assessment of methodological quality Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix V). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data collection Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix VI). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratios (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest No conflicts to declare. Acknowledgements Ms Ella Gagolkina for undertaking secondary critical appraisal of papers that met the inclusion criteria. Assoc. Prof. Craig Lockwood for assistance, direction and supervision. 10.11124/jbisrir-2014-1284 Page 92
References 1. Firth-Cozens, J. Emotional Distress In Junior House Officers. BMJ.1987; 295(6597): 533-536. 2. Willcock SM, Daly MG, Tennant CC, Allard BJ. Burnout and psychiatric morbidity in new medical graduates. Medical Journal of Australia.2004; 181(7): 357-360. 3. Brown MA, Arnold S. A day in the life of a doctor-in-training. Medical Journal of Australia.2008; 188(9): 500-501. 4. Jenkins KD. Keeping the doctor healthy: ongoing challenges. Medical Journal of Australia.2009; 191(8): 435-435. 5. Markwell AL, Wainer Z. The health and wellbeing of junior doctors: insights from a national survey. Medical Journal of Australia.2009; 191(8): 441-444. 6. Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Suicidal ideation among medical students and young physicians: a nationwide and prospective study of prevalence and predictors. Journal of Affective Disorders.2001; 64(1): 69-79. 7. Shapiro SL, Shapiro DE, Schwartz GER. Stress management in medical education: A review of the literature. Academic Medicine.2000; 75(7): 748-759. 8. Tyssen R, Vaglum P. Mental health problems among young doctors: An updated review of prospective studies. Harvard Review of Psychiatry.2002; 10(3): 154-165. 9. Pilotto LS, Duncan GF, Anderson-Wurf J. Issues for clinicians training international medical graduates: a systematic review. Medical Journal of Australia.2007; 187(4): 225-228. I 10.11124/jbisrir-2014-1284 Page 93
Appendix I: Appraisal instruments MAStARI appraisal instrument this is a test message Insert page break 10.11124/jbisrir-2014-1284 Page 94
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Appendix II: Data extraction instruments MAStARI data extraction instrument Insert page break 10.11124/jbisrir-2014-1284 Page 97
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