Introduction
The transition into postgraduate specialty medical training can be a challenging time for new trainees. Awareness of the importance of protecting the wellbeing of trainees across all medical specialties has increased, especially since the coronavirus disease 2019 (COVID-19) global pandemic [1].
Previous international research shows that trainees in some surgical specialties are at higher risk of burnout than their peers in other specialty training programs [2]. In Australia, levels of burnout and poor wellbeing are high across all surgical specialties [3]. Burnout in surgical trainees has been linked to poorer overall mental and physical health for trainees, as well as substance abuse and lower job satisfaction [4].
Despite increased understanding of the prevalence and risks of burnout and poor wellbeing in surgical training, only a small number of qualitative studies have been conducted, especially in the Australian context [5-7]. None have explored Australian surgical trainee perceptions of the relationship between burnout, wellbeing, and the surgical training environment. Therefore, this study aimed to explore surgical trainees’ experiences in the surgical learning environment in terms of occupational job demands that impact wellbeing and the resources that can support trainees.
Methods
1. Design and theoretical lens
This study used a longitudinal qualitative research design, and is a part of a larger mixed methods longitudinal study. The Job Demands-Resources (JD-R) model was used to provide a theoretical framework through which to examine the reciprocal relationship between job demands and job resources [8,9]. Job demands are aspects of the work environment that require the employee to expend physiological and/or psychological effort to manage, such as high workload or emotionally demanding client interactions [8]. Job demands are not inherently negative; however, they can lead to burnout if they require ongoing effort from an employee without sufficient recovery time or resources [8]. Conversely, job resources are aspects of the work environment that reduce job demands, assist employees in achieving work goals, and foster growth and development [8]. The JD-R model is an effective model for understanding burnout and wellbeing in healthcare workers and has previously been used in qualitative studies of healthcare practitioner wellbeing [10].
2. Ethics
Ethical approval was obtained from the University of Wollongong Human Research Ethics Committee (HREC 2020/237). Participants received a participant information sheet which explained the nature and purpose of the research and contained details of free confidential mental health support services in the unlikely event that it would be required. Participants were asked to provide written consent and advised that they could discontinue the interview at any time.
3. Participants and recruitment
Participants for this study were recruited from the larger longitudinal study. For that study, surgical trainees were recruited using convenience sampling. The Australian orthopedic, vascular, general and urology surgical specialty societies distributed an email invitation to all their trainees commencing training in 2021 and 2022 on behalf of the study team. An additional invitation was included in the trainee newsletter distributed by the Royal Australasian College of Surgeons. The remaining surgical specialty societies (plastic surgery, pediatric surgery, cardiothoracic surgery, neurosurgery, and otolaryngology) either declined or did not respond to the request to send out the study invitation. At the completion of that study, participants were asked to provide their contact details if they were willing to take part in an interview to explore their experiences in more detail.
4. Data collection
Semi-structured interviews were conducted virtually by the lead author (B.B.) using the Zoom (Zoom Video Communications Inc., San Jose, USA) or Microsoft Teams (Microsoft Corp., Redmond, USA) videoconferencing platforms. Participants were interviewed at baseline (one trainee prior to commencement of training and the remainder within the first 4 weeks of the training program), and then invited by email to participate in a second interview approximately 18 months later. The interviews consisted of a series of open-ended questions exploring what participants perceived to be the positive and negative aspects of their surgical training, and how these experiences impacted their wellbeing. The second interview additionally explored changes in experiences over the first 12–18 months of training. The interview guides were piloted with two trainees and adjustments made according to their feedback.
5. Data analysis
Interviews were transcribed verbatim and all potentially identifying information was removed. A copy of each transcript was emailed to the relevant participant prior to analysis for verification. Transcripts were then imported into QSR NVivo ver. 12.0 (QSR International, Melbourne, Australia) for coding and analysis.
Thematic analysis was conducted using an inductivedeductive approach. Interviews were analyzed deductively using the JD-R theory as a scaffold. Inductive analysis was used to add new themes as they emerged from the data. The Consolidated Criteria for Reporting Qualitative research checklist (COREQ-32) was used to guide reporting of this research.
6. Rigor and reflexivity
To increase rigor and reduce bias, researcher triangulation was used. Two researchers (B.B. and H.S.) coded the transcripts together. The coding framework was continually adjusted and refined by discussion and consensus as the analysis progressed. A third researcher was available should consensus not be reached. The research team comprised an experienced researcher with over a decade in surgical education (B.B.), a public health academic with extensive experience in qualitative research methods and analysis (H.S.), and an orthopedic surgeon with extensive experience in surgical education and working with surgical trainees (N.W.).
Results
Eleven interviews were conducted with seven trainees. Four took part in the second interview; two did not respond and one was not available due to illness. Participant information is provided in Table 1. Speciality has not been provided due to the possibility of identifying participants. The average interview duration was 37 minutes (range, 18–54 minutes). No new themes were identified after the sixth interview.
Seven themes were derived: (1) relationships with colleagues, (2) work hours and workload, (3) the learning environment and supervision, (4) training program requirements, (5) moving around, (6) hospital and team administration, and (7) hospital facilities and programs and are discussed below. Participant experiences between training commencement and 18 months follow-up did not change.
Table 2 categorizes the demands and resources discussed under each theme as relating to systems (the systemic level) or the individual.
1. Relationships with colleagues
Relationships included those with supervisors, other trainees, nurses, and unaccredited registrars, and were the most prevalent theme. Strained and dysfunctional relationships between trainees and their colleagues were a significant occupational demand that detrimentally impacted their wellbeing. Having opportunities to connect with senior staff outside of the operating theatre could assist with building relationships and creating positive work environments:
If you’ve shared a meal with your boss and talked about their children, then the next time you’re in theatre with them, they’re more likely to look you in the eyes and teach you stuff, and they’re less likely to shout at you about something. (Participant 3)
Equally, several participants reported that positive collegial relationships functioned as an important resource that could counterbalance the negative impacts on wellbeing of other job demands. Working in a good team could “make or break” a rotation that would otherwise be unenjoyable and stressful. In particular, participants felt that a positive team culture encouraged them to contribute, and made them feel more confident that their contributions would be noticed and valued. This in turn made the term more enjoyable and allowed them to learn and achieve more than they would in a more punitive environment:
[It was] one of those environments that lends itself to you feeling like if you had something to say, then that people would think about it and actually consider your point of view. …any point of view was valid. (Participant 7)
Participants felt that poor treatment of new trainees by more senior colleagues was a cultural problem, with senior colleagues perpetuating the negative behavior that they experienced in their early years of training. Regardless, participants reported that their training experience was still generally more enjoyable than that of a pre-training registrar because their colleagues treated them with more respect, and they had access to more teaching and learning opportunities.
2. Work hours and workload
Almost all participants reported excessive work hours as being significantly detrimental to their physical and psychological wellbeing. Some reported working several days in a row without sufficient sleep or breaks, and one noted that external factors such as the COVID-19 pandemic and natural disasters, made it much more difficult to cope with the demands of long working hours:
Had a weekend a couple of weeks ago where I arrived at work at 6 AM on Saturday and I left at 1 AM on Monday morning, and in that time I’d had like 90 minutes of sleep on a mattress on the floor of my office …I remember I called my partner and cried during the floods, and I’m not a crier, I don’t cry very often …it was a terrible, terrible time. (Participant 4)
Several participants discussed the impact of the ongoing cultural perception of what was considered “normal” work hours for surgeons. Some commented that working long hours was seen as a requirement for trainees to prove that they are competent and serious in their career ambitions. Whilst official policies and procedures were in place in many hospitals to protect trainees from working unsafe hours, they were often not adhered to in practice:
One of the bosses was like, “Oh, you can’t do that, you need to have a fatigue management plan if you’re going to [work several days in a row]” …Then the same boss, when [the trainee had] been awake all night until 5am operating on behalf of him, and she said the next morning, “Hey can I go home, I’ve been up all night,” he said, “No, this is training!” (Participant 3)
Not all participants felt that long work hours were harmful. Some felt that their most enjoyable terms were also the busiest, because those terms provided a variety of interesting cases and learning experiences, allowing trainees ample opportunities to develop their skills. Furthermore, some argued that restricting work hours could detrimentally impact competency due to reduced learning hours, and that restrictions would only increase levels of unpaid overtime. Efficient, actively monitored rostering practices that ensured trainees had regular time off were suggested as a more effective way of managing the demand of long working hours. This would allow trainees struggling with fatigue and overwork to be identified and properly supported before their wellbeing was negatively impacted. The importance of role modelling of healthy behavior was also noted. When surgeons in leadership positions prioritized wellbeing and work-life balance for themselves, this created a top-down flow-on effect and made it easier for those lower in the hierarchy to do the same:
The consultants work incredibly hard, but the head of the unit, he has four children, and he really values everyone seeing their families and doing stuff outside of work while also working hard. (Participant 6)
For many participants, excessive work hours were frequently the result of unmanageable workloads. Clinics and operating lists could take up so much time that trainees had to come into the hospital early or stay late to complete administrative tasks and training requirements. Having sufficient time set aside for study and administrative tasks was seen as a crucial resource for wellbeing:
Making sure that there’s enough sort of downtime within a week where you have got no clinic or no operating, where you can catch up on the limitless paperwork jobs or the audit, or stuff like that, so that’s it’s not being pushed back until you’re doing it at 6-o-clock after work. (Participant 2)
Participants suggested the best way to achieve this was to ensure that the unit was adequately staffed to share the workload across the team. In units where there were sufficient staffing levels, trainees had some flexibility to proactively adjust the demands and resources of their job, such as being involved in interesting operative cases or use downtime to study. This had a positive impact on their wellbeing and job satisfaction. It also made it easier for them to take days off for sickness or personal reasons because there were enough people to cover their shifts.
The value of strong and clear team leadership for protecting wellbeing was clearly highlighted. Trainees reported that when the senior people in the team had a clear idea of how they wanted the team to run and each member of the team was clear on what their job was, work ran smoothly and had a positive impact on staff wellbeing:
In teams where the seniors take a very clear cut and directed approach to how they want the unit to run, that has a very positive impact on the experience of the term because there’s no ambiguity…everything runs smoothly and it makes bigger workloads easier to deal with, because everyone knows what their responsibility is. (Participant 5)
3. Learning environment and supervision
Several participants reported that the learning environment within a department impacted their wellbeing. First year trainees felt a lot of pressure to perform well and demonstrate their competence. This significant pressure could detrimentally impact their wellbeing, especially if the learning environment was not conducive to making mistakes. Conversely, a positive learning environment acted as a resource for trainees by allowing them to ask questions and learn from each other:
If we could have an environment which was accepting of people getting wrong answers, and that’s okay, you might not have that knowledge yet, but will get there. You shouldn’t be ashamed to ask questions, you should be trying to broaden your knowledge. I think that would be a good thing to help with people’s well-being. (Participant 7)
Participants appreciated regular, formal, and clear feedback on how they were progressing. The importance of well-defined orientation procedures at the beginning of each rotation to ensure they know what was expected for them was also highlighted:
Different hospitals do things differently, and the best are the ones that have a formative process where you have to attend a 3-month and a 6-month half term, mid-term and end-of-term feedback session, and then you have a clear orientation as well at the start of that …it’s really good because it sets out what’s expected of you. (Participant 2)
Several participants spoke of the value of mentoring for good wellbeing. Having a mentor to whom they could reach out for advice and counsel, provided them with an important ongoing support network as they moved through their rotations. Supervisors and senior staff taking an active interest in their professional development and career goals was seen an important factor in promoting wellbeing and effective learning, and overcame power imbalance barriers:
It was actually the seniors taking an interest in what’s happening in their juniors’ professional lives [that made the trainee feel valued]. It was a very informal process as well. The initiative was from the boss to come and sit down and say…what are your goals? And what have you done to achieve your goals? And how can we help make that happen? That’s something I'm very appreciative for. (Participant 5)
Several participants discussed the importance of having agency and autonomy and how this acted as a key resource to counteract job demands. When trainees were given gradual autonomy and developmental opportunities appropriate to their experience level, they were more likely to enjoy the term and feel well at work. However, whilst they appreciated being trusted to operate independently, they also needed the assurance that support would be available when they were facing a task that was beyond their capability.
4. Training program requirements
Participants discussed the stress caused by the academic demands of the surgical training program, particularly the fellowship examination. Despite only being new trainees and the exam not occurring until around the fourth year of study, some already spoke of the significant time commitment required to study for the fellowship examination, and how this could impact relationships with their families. For some, this stressor was due to watching more senior trainee’s wellbeing deteriorate because of the stress of preparing for the examination:
She had a young child, had just failed exams for a second time. She’d be on the on-call phone and she’d just explode at people. She was pretty short with everyone, including people on her own team. She became quite work avoidant, would try to dish off tasks and her operative skills suffered …she’s probably a great example of someone that wasn’t coping …I wouldn’t be coping either you’ve just failed your second lot of exams which would have cost you like, I don’t know, 30 grand and 2 years of your life and you’ve got a young kid at home, horrible. (Participant 4)
Whilst other training requirements were not discussed as frequently as the fellowship examination, some highlighted that their workload often did not allow them sufficient time to collect workplace-based assessments and other assessments required to progress in training. Having several different training institutions also made the process more time-consuming than it needed to be. Others highlighted that some mandatory formal education sessions were scheduled outside of working hours or on weekends. This cut into their already limited time outside of work and impacted family life. The significant financial cost of training and examinations and the negative impact it had was also highlighted, especially for those with families to support and who were required to pay relocation expenses:
We have to relocate [for training], we have to move from state to state, and our relocation expenses, there’s no subsidy for our $8,500 a year to offset that cost …I know several people who have come to difficulty from the financial side of things. (Participant 5)
5. Hospital and team administration
Several participants reported that poor administrative practices within their team or the hospital more broadly could be a significant occupational demand. Trainees who had to spend excessive time on administrative tasks felt that they did not have sufficient time for their patients and clinical decision-making:
Most of the time I spend is not on actual clinical decisions or working with the patients, but just running around trying to figure out how to print some forms, struggling with IT, etcetera …I’m constantly frustrated and angry, and because of that I also do not feel safe. I spend so much time on minor things that I don’t have time for major things. (Participant 1)
Participants highlighted how effective team leadership and administration could help them deal with workplace demands. One trainee gave an example of a team where late-night shifts are balanced between staff members so that others did not feel obligated to stay back:
I think it’s really good when it’s clear amongst the team that like, only this person is going to stay late tonight and everyone else needs to take care of themselves and go home and eat and sleep and have a good night, rather than everyone hanging back. (Participant 3)
Others highlighted how ineffective leadership could be detrimental for wellbeing, particularly when trainees were having difficult or challenging experiences were. One trainee described how, when one of their colleagues was struggling with burnout, there were no procedures in place to assist them or address the problem:
It was only after a sustained period of time that we realized that this guy was probably quite burnt out. When that came to light, the only thing that really changed was just trying not to burden him with anything else …But there wasn’t a lot of formal support…In the end, the solution was that he was moved from that clinic to a different task. So, he was offloaded in that sense, but the actual problem wasn’t addressed, because someone else has to do that same thing. (Participant 7)
6. Hospital facilities and programs
Several participants spoke of the ways in which a lack of hospital facilities can exacerbate job demands. One participant spoke of a lack of dedicated sleeping space at their hospital, which forced them to choose between driving home tired or finding somewhere in the hospital to sleep:
Because you try and drive home, even that Sunday night I drove home with my lights off the entire way and didn’t realize until I got onto my street …We were sleeping in empty patient rooms within the pediatrics ward. I was sleeping in one of those for four nights. (Participant 4).
Participants appreciated the potential value of knowing wellbeing initiatives were available to them to help balance job demands. However, in some cases, initiatives were not widely known about. Opportunities to raise awareness of wellbeing initiatives, such as during orientation sessions for new trainees, were frequently not used or not in existence at all. Well-intentioned initiatives that were ultimately ineffective because they were not fit for purpose or not designed in consultation with trainees were highlighted. For example, having a senior department member appointed as a wellbeing officer would not be effective if trainees did not feel comfortable discussing wellbeing concerns for fear of potential future consequences. Participants also stated that wellbeing initiatives were only useful if they were implemented thoughtfully, promoted consistently, and there could not be a one size fits all model.
There’s a midday Friday meditation session …But I have never met a single doctor who is able to attend that at midday on a Friday, because we’re all working …no-one takes your phone or your pager away from you or tells the nurses not to call you at that time. (Participant 3)
7. Moving around
Securing a training position brought a certain amount of job security for trainees because they were guaranteed a position for the full duration of their training program. This eliminated the stress of having to reapply for a job every year, as was required during unaccredited training. However, the requirement of having to rotate through different hospitals for 6 to 12 months at a time, often in regional hospitals, placed demands on wellbeing for many trainees, especially those that had to uproot partners and children, or leave them behind:
My partner’s back in [capital city], and I’m in [regional town] at the moment, which is 3 hours away. Next 6 months I’m in [different regional town] which is an hour away. And then next year, I have no idea. And I just have to say to him, I might be living with you next year, I might not, which is probably the thing that weighs on me the most. (Participant 6)
Participants who were away from their usual home during a rotation reported that moving around made it difficult to keep up activities that were beneficial to good wellbeing, such as exercising. By the time they found a gym and established a new routine, it was time for them to leave again. Whilst moving between hospitals was acknowledged as a necessary process for breadth of training, participants suggested that the negative impact could be reduced if they had more notice of upcoming rotations and longer periods of stability:
Moving towns and states every 6 months is soul crushing at times …If you were told in 18 months you’re going to be in [a regional town] for 6 months or 12 months, that makes life so much more manageable. I think I found out at the start of December that at the end of January I was leaving. (Participant 4)
Participants also highlighted that it could be difficult to create and maintain effective collegial relationships when moving between hospitals on a regular basis, particularly if the hospital and department did not have established orientation processes. One participant suggested that hospitals and training institutions should be more proactive at providing practical support for trainees rotating outside of their home city, like the military did:
If you’re going to move people around the country against their will, you should take the cue from the military …
They have first fit childcare centers which will always take military people, they can skip the queue to an extent because they have to organize things on a short basis. Why don’t we have that? (Participant 7)
Discussion
This study explored the experiences of Australian surgical trainees in the surgical learning environment and identified some of the key factors that impact their wellbeing. Resources and demands that impact trainee wellbeing include relationships with colleagues, work hours and workload, the learning environment and supervision, moving around, hospital and team administration, and hospital facilities and programs. Most demands and resources that impact wellbeing operate at the systemic level rather than an individual level.
The importance of strong collegial support for protecting against burnout and poor wellbeing is well documented [11,12]. Lack of workplace support and poor peer support networks are key demands that are associated with higher risk of mental health concerns and poorer wellbeing [13]. Participants in this study felt that lack of support and poor treatment of new trainees was partially due to a cyclical perpetuation of cultural norms, passing each new generation of trainees through a socially shared ordeal of working through physical and mental discomfort to achieve what Veazey Brooks and Bosk [14] in 2012 refer to as “the surgical personality.” Attempts to shift this cultural norm are viewed as an erosion of professional standards and personal entitlement making the cycle difficult to break without a whole of system approach [14]. Some studies have identified support mechanisms that show potential for building collegiality and changing the learning culture, including regular debriefing and team building exercises [15]. However, these can be challenging to implement due to lack of time and reluctance of surgeons to participate. Although formal interventions can be difficult to implement, informal social bonding opportunities can be equally effective and can occur spontaneously when trainees and senior colleagues can decompress and debrief together between shifts [16]. These opportunities for building relationships and informal mentoring can provide trainees with crucial social connections that support wellbeing and prevent burnout. Relationships with non-surgical colleagues, such as nursing staff, are equally important, as they can provide additional support and learning opportunities when trainees are working outside of their regular team or hours [17].
Previous research on the relationship between burnout and working hours is mixed: some studies have found that work hours do not predict burnout in healthcare workers [18]; others suggest that excessive work hours (generally in excess of 60 hours per week) are associated with increased risk of burnout, lower job satisfaction, and psychological distress [19]. We found that excessive working hours are a common demand that has a significant negative impact on trainee wellbeing. Participants highlighted that simply reducing or restricting working hours was not necessarily an adequate solution, because it could lead to poorer competency in trainees and unintended increases in unpaid overtime. This is consistent with other research that showed how work hour restrictions have a negligible impact on trainee wellbeing and can worsen the educational experience [20]. We found three potential resources to buffer the effects of excessive working hours. Firstly, more effective rostering and scheduling of shifts may be an alternative solution to managing work hours. While operating rosters are commonly put together by consultants or senior trainees, the use of programming and statistical modelling has been shown to provide a fair and efficient solution to allocating shifts and work hours fairly across a department, whilst reducing the administrative load in the unit [21]. Secondly, having sufficient staffing levels had a positive impact on trainees’ ability to maintain balanced working hours. Having enough staff to comfortably cover the workload in a department can allow trainees to take time off to rest and recover, and enable protected non-clinical time, all of which can protect against burnout [22]. Finally, active monitoring of trainee working hours and role modelling of healthy behaviors by supervisors and senior colleagues can protect against the negative effects of excessive hours. Indeed, burnout analyses by specialty show that rates of burnout amongst trainees tend to mirror those of consultants and negative faculty role modelling increases the risk of depression for trainees [23]. On the other hand, effective role modelling can contribute to breaking the culture of working excessive hours being part of the nature of surgery by influencing the behavior of the next generation of surgeons [24].
Our results highlight the importance of a positive learning environment for promoting trainee wellbeing, particularly establishing a culture of safety that is accepting of questions and occasional mistakes. When an error is made, trainees should be supported to reflect on the error with constructive feedback, open communication, and transparency. This facilitates future learning and growth and reduces the impact of the error on the trainee’s wellbeing [25]. A culture of safety can also improve the educational impact of feedback, which is more effective when delivered by a supervisor who is respected by the trainee [26]. While culture change can be slow and difficult, some interventions have demonstrated positive results, such as teamwork training and patient safety checklists [15]. Allowing trainees a sense of control and professional autonomy can also improve wellbeing and reduce the likelihood of burnout [27].
Participants in this study identified mentoring as a resource for buffering the harmful effects of workplace job demands. This is in line with other research which states that mentoring can promote supportive cultures and foster the development of social capital [28]. Mentoring relationships are more likely to be successful when the mentorship is formalized as a professional activity [29], which is particularly important for surgical trainees who rotate between different sites on a regular basis and may therefore have difficulty establishing and maintaining long-term mentoring relationships. The Royal Australasian College of Physicians and Australian Orthopaedic Association have recognized the importance of formal mentoring for trainees and provide resources on their websites to support the establishment of mentoring relationships. Structured evaluation of the effectiveness of pilot programs such as this may help inform the development of similar programs in other specialties.
It is important to note that trainees in this study had varied experiences. some reported having a difficult and demanding training experience which had significant negative impacts on their personal wellbeing, while others had more positive experiences. For most trainees, their experiences varied between training sites according to the demands and resources present at each site, as well as their own personal situation at the time of the rotation. This highlights that subjective wellbeing is an inherently personal concept that varies across individuals, and within individuals over time. For this reason, it is important to consider the impact of system-level wellbeing interventions on individuals and the need to build in flexibility to maximize effectiveness. For example, out-of-hours social events may be an effective way to connect with colleagues and build workplace social networks, but may not be appealing or practical for trainees with family commitments who may feel excluded because they chose to prioritize time outside of work with their family, and that they are missing out on opportunities afforded to other members of their team.
This study has limitations. Firstly, it is a small-scale study that does not include representation from all surgical specialties or regions, and the results may not fully represent the experiences of the broader cohort. Participation was voluntary and it is possible that those that did not participate may have had different views and experiences. However, participants reported a range of positive and negative experiences relating to their wellbeing, and we believe the cohort is well balanced.
In conclusion, this research highlights that a range of demands can impact trainee wellbeing in the workplace. Trainee experiences vary significantly between training sites, demonstrating that more work is required to create consistent, positive, and safe learning environments. Resources that address the most significant demands for trainees, such as collegial relationships, work hours and workload, the learning environment and moving around should be prioritized. The implementation and evaluation of such resources at system level should be a priority for future research.
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