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ORIGINAL ARTICLES

Differential Impacts of the COVID-19 Pandemic on Mental Health Symptoms and Working Conditions for Senior and Junior Doctors in Australian Hospitals

Pascoe, Amy BSci, BBiomedSci(hons), PhD, Eldho Paul, PhD; Johnson, Douglas MBBS(hons), B.Com, DTM&H, CTH, PhD, FRACP; Putland, Mark MBBS, GradCertEmergHealth, GradCertClinResMeth, FACEM, MPH; Willis, Karen GradDip(Health Promotion), PhD; Smallwood, Natasha BMedSci, MBBS, SpecCertPallCare, MSc, FRCP, FRACP, PhD

Author Information
Journal of Occupational and Environmental Medicine: May 2022 - Volume 64 - Issue 5 - p e291-e299
doi: 10.1097/JOM.0000000000002505

Doctors face unique workplace demands and stressors in their daily work environments. These stressors include but are not limited to: excessive working hours,1 career stress,2 risk of exposure to communicable disease3 or violence and aggression,4 and high levels of critically important clinical and administrative responsibilities.5 Consequently, doctors are at increased risk of mental illnesses, including anxiety and depression,6,7 burnout,8 and suicidal ideation9 compared to the general population.

While some occupational demands are similar, workplace stressors and associated impacts on mental health can vary according to seniority of medical staff. A survey of 12,252 Australian doctors conducted by Beyondblue in 2013 reported symptoms of common mental disorders were present in one third of the trainees10 compared to one in four consultants working across all specialties as detected on the General Health Questionnaire.6 Similar findings have been reported internationally, with Irish trainees experiencing greater levels of psychological distress and resistance to seek help than consultants.11

Since the onset of the COVID-19 pandemic, healthcare workforces have endured massive workplace changes with rapid widespread adoption of telehealth,12 large new volumes of information,13 major changes to work practices including the routine use of personal protective equipment (PPE), resource shortages,14 and redeployment.15 Changes to rules regarding hospital visitors have at times led to conflict and distress16 and some healthcare workers (HCWs) have at times been furloughed (placed in mandatory isolation due to exposure) or concerned they would be blamed by colleagues if they become infected with COVID-19.15 Outside the workplace, HCWs have endured various local lockdown restrictions,17 stigma from the community that they are responsible for spreading the virus and been highly worried about transmitting infection to their families.16 Internationally, patient care has been rationed out of necessity, and has been a source of intense moral distress for some healthcare workers.18 Although caseloads of people infected with COVID-19 in Australia during the first and second wave of the pandemic were relatively low19 and did not reach levels that exceeded hospital capacity, anticipation of surging cases and pre-emptive workplace changes have been persistent stressors. Furthermore the capacity of many healthcare systems will continue to be tested as governments move towards approaches of “living with COVID-19.”20

Redeployment and prioritisation of caseloads are likely to have follow on effects on the career progression of junior doctors, with delayed recruitment schedules and cancellation of educational opportunities such as seminars and workshops.21 Whilst the Medical Board of Australia has moved to waive mandatory rotation requirements,22 these lost training opportunities are likely to have ongoing impacts on junior doctors’ expertise and confidence. Although impact of increased caseload on the broader healthcare system has been discussed extensively, little work has focused on the impacts on senior doctors facing reduced workloads or income, including those working in specialist areas impacted by cancellations of “non-essential” procedures. Understanding the specific and varied challenges faced by junior and senior doctors during this time is essential to support these workforces during ongoing and future crises.

The Australian COVID-19 Frontline Healthcare Workers Study investigated psychological, financial, and occupational disruptions faced by Australian healthcare workers during the COVID- 19 pandemic.23 This paper reports a subset of findings from Australian junior and senior hospital medical staff, and aims to examine the type and frequency of workplace and social disruptions, as well as the prevalence and predictors of mental health symptoms and moral distress experienced by each group as a result of COVID- 19. We hypothesised that the prevalence and predictors of mental health symptoms would vary according to the seniority of doctors.

METHODS

Study Design and Sample

The full study methodology and survey has been published.23 In summary, a nationwide, voluntary, anonymous, online survey was conducted between August 27 and October 23, 2020. The survey ran concurrently with the Australian second wave of the pandemic, which occurred primarily in Melbourne, Victoria, which was subjected to stringent lockdown restrictions for a prolonged period.17 Self-identified Australian frontline healthcare workers were invited to participate via a broad dissemination strategy. CEOs and departmental directors of all Victorian public hospitals and multiple hospitals nationwide were contacted by the investigator team via email and asked to share the survey information with colleagues. Participating groups included 36 professional societies, colleges, universities, associations and government health department staff. Media outlets provided additional coverage of the survey, including 117 newspapers, 8 television and radio news items, and 30 social media sites. Participants did not need to have direct contact with people infected with COVID-19 to take part. No incentives for participation were offered. Data from general practitioners has been analyzed and reported separately and as such, only medical staff working in hospitals were included in the current analysis.

Data Collection

The survey was a single timepoint measure with no longitudinal data collected. Participants completed the survey questionnaire via a direct link or through a purpose-built website. Data collected included demographics; professional, occupational, and home circumstances; organisational leadership and workplace disruption. Mental illness was determined subjectively by participants (self-reported) and five validated, objective mental health symptom measurement tools (the Generalised Anxiety Disorder (GAD-7)24: Patient Health Questionnaire (PHQ-9),25 abbreviated Impact of Event Scale (IES-6),26 abbreviated Maslach Burnout Inventory (MBI),27 and abbreviated 2-item CD-RISC-2 scale to measure resilience28). Four indicators of moral distress were generated by drawing on contemporary literature about moral distress,29 key insights about the applicability of moral distress during the COVID-19 pandemic,30 and consensus discussions amongst the research team. Participants self-reported if they were a senior doctor (ie, consultant specialist) or junior doctor (all other grades).

Statistical Methods and Data Analysis

All analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). Demographic and socioeconomic characteristics are reported descriptively. For each mental health scale, outcomes were categorised into dichotomous variables as described in Smallwood, Karimiet et al.23 The association between hospital medical staff seniority (junior or senior doctor) and predictor variables, including workplace changes, training and confidence, impacts on relationships, and mental health outcomes were assessed using chi-square tests. Independent t-tests were used to compare mean scores on numerical Likert scale measures of confidence and resilience.

Predictors of mental illness symptoms were identified using univariable and multivariable logistic regression models separately for both junior and senior doctors. Given the different working conditions for junior and senior medical staff it was decided a priori to conduct separate regression models to identify predictors for mental illness symptoms in each group. Covariates examined in univariable analyses were assessed for clinical and biological plausibility and included: age, gender, state, lives alone, lives with children, lives with elderly people, frontline area, practice location, works with COVID-19 patients, anticipates working with COVID- 19 patients, received personal protective equipment (PPE) training, worried their role will lead to COVID-19 transmission to family, worried about being blamed by colleagues, close friends or relatives infected with COVID-19, changed relationships with partner or friends or family or colleagues, changed household income, concerns regarding household income and pre-existing mental health diagnoses. Variables with a P value of less than 0.10 on univariable were considered for inclusion in the multivariable models. Multivariable models were developed using stepwise selection and backward elimination procedures before undergoing a final assessment for clinical and biological plausibility. Results from the regression models are presented as odds ratios (OR) with 95% confidence intervals (95% CI) and forest plots. A two-sided P value less than 0.05 was chosen to indicate statistical significance.

RESULTS

Demographic Characteristics

A total of 9518 frontline healthcare workers responded to the survey, with 7846 (82.4%) deemed sufficiently complete for analysis. Of these, 1966 (20.7%) were hospital medical staff, who provided complete responses for analysis. Nearly two thirds were senior doctors (1221, 62.1%) and the remainder were junior doctors (745, 37.9%). Most of the junior doctors (700, 94.0%) were aged under 40 years (Table 1). Junior doctor respondents were predominantly female (536, 71.9%), whereas the sex of senior doctors was more evenly balanced. Most respondents resided in the Australian state of Victoria and practiced in metropolitan locations. Senior doctors were significantly more likely to live with children (P < 0.001) or adults aged over 65 (P = 0.002) compared to junior doctors.

TABLE 1 - Participants’ Characteristics
Senior Doctors (n = 1221) Junior Doctors (n = 745)
n % n % P
Age (years) < 0.001
 20-30 3 0.2 361 48.5
 31-40 325 26.6 339 45.5
 41-50 483 39.6 38 5.1
 50+ 410 33.6 7 0.9
Sex < 0.001
 Male 498 40.8 203 27.2
 Female 715 58.6 536 71.9
 Non-binary/ Prefer not to say 8 0.7 6 0.8
Australian State 0.002
 Victoria 932 76.3 613 82.3
 Other states 289 23.6 132 17.8
Location of practice 0.407
 Metropolitan area 1068 87.5 661 88.7
 Regional / Remote area 153 12.5 84 11.3
Health organisation type
 Public 1118 91.6 735 98.7 < 0.001
 Community 277 22.7 33 4.4 < 0.001
 Private 470 38.5 54 7.2 < 0.001
 Other 58 4.8 9 1.2 < 0.001
Current Employment Status < 0.001
 Full time 657 53.8 656 88.1
 Part time 528 43.2 63 8.5
 Casual/other 36 2.9 26 3.5
Lives alone 145 11.9 133 17.9 < 0.001
Children <16 years at home 684 56 164 22 < 0.001
Lives with > 1 elderly person /people at home 109 8.9 38 5.1 0.002
Multiple options could be selected.

Workplace Environment and Change

Both senior (629, 51.5%) and junior (301, 40.4%) doctors reported working increased hours during the pandemic (Table 2). Junior doctors were significantly more likely to report working increased paid hours (P = 0.009), whereas senior doctors were significantly more likely to report working increased unpaid hours (P < 0.001). Senior doctors were also significantly more likely to experience a decrease in household income (P < 0.001) and to report concerns about their household income (P = 0.009) compared to junior doctors. Nearly one quarter of junior doctors were redeployed (171, 23.0%) and a quarter (191, 25.6%) experienced a change in work role. Of the doctors who were redeployed, junior doctors were significantly less confident in their new work area or role compared to senior doctors. Both junior and senior doctors reported receiving useful communication and mental health support from their workplaces.

TABLE 2 - Workplace Environment and Exposure to COVID-19
Senior Doctors (n = 1221) Junior Doctors (n = 745)
n % n % P
Frontline area <0.001
 Emergency Department 173 14.2 159 21.3
 ICU 92 7.5 94 12.7
 Anaesthetics/peri-op/surgical 261 21.4 74 9.9
 Medical specialty areas 642 52.6 391 52.5
 Other 26 2.1 15 2.0
Community
 Changed working hours since the pandemic commenced§ 27 2.2 12 1.6
 Increased paid hours 203 16.6 159 21.3 0.009
 Increased unpaid hours 426 34.9 142 19.1 <0.001
 Decreased paid or unpaid hours 224 18.3 40 5.4 <0.001
 No change 464 38.0 443 59.5 <0.001
Change in household income due to the pandemic <0.001
 Increased 116 9.5 69 9.3
 Decreased 512 41.9 145 19.5
 No change 593 48.6 531 71.3
Concerns or worries about household income since the pandemic 307 25.1 149 20.0 0.009
Redeployed to a new area of work 122 10.0 171 23.0 <0.001
Confidence in new area (mean [SD]))|| 5.4 (1.4) n = 122 4.9 (1. 3) n = 171 0.002
Change in work role 274 22.4 191 25.6 0.106
Confidence in new role (mean [SD])||Exposure to COVID-19 5.4 (1.1) n = 271 4.8 (1.2) n = 190 <0.001
 Currently working with people infected with COVID-19 524 42.9 436 58.5 <0.001
 Anticipates working with people infected with COVID-19 531 76.3 277 89.6 <0.001
 Exposure to confirmed COVID-19 patients 302 24.7 284 38.1 <0.001
 Exposure to suspected COVID-19 patients 664 54.4 582 78.2 <0.001
 Quarantined or furloughed due to exposure to COVID-19 88 7.2 95 12.8 <0.001
 Undergone testing for COVID-19 908 74.4 645 86.6 <0.001
 Tested positive for COVID-19 7 0.8 18 2.8 0.002
 Received training to care for patients with COVID-19 536 43.9 313 42.0 0.413
 Confidence caring for people with COVID-19 (mean [SD])|| 5.0 (1.53) n = 1051 4.7 (1.42) n = 711 <0.001
 Received training on PPE during the pandemic 923 75.6 626 84.0 <0.001
 Confidence using PPE (mean [SD])|| 5.3 (1.54) n = 1056 5.3 (1.41) n = 713 0.764
 Desires more training regarding PPE or managing people with COVID-19 582 55.1 421 59.0 0.102
 Close friends/relatives infected with COVID-19 in Australia or overseas 416 34.1 321 43.1 <0.001
Communication received from the workplace during the pandemic has been useful and timely Strongly or somewhat agree 854 69.9 520 69.8 0.227
 Neither agree nor disagree 155 12.7 79 10.6
 Strongly or somewhat disagree 212 17.4 146 19.6 0.490
Believed their workplace actively supported their wellbeing and mental health during the pandemic Strongly or somewhat agree 764 62.6 457 61.5
 Neither agree nor disagree 234 19.2 136 18.3
 Strongly or somewhat disagree
Worried about being blamed by colleagues if they contract COVID-19 223 18.3 152 20.4 0.048
 Strongly/somewhat disagree 257 21.0 129 17.6
 Neither agree nor disagree 195 16.0 107 14.4
 Strongly/somewhat agree
Worried their role will lead to them transmitting COVID-19 to family 769 63.0 745 68.3 <0.001
 Not worried 163 15.4 77 10.8
 Neutral 143 13.5 67 9.4
 Very worried 750 71.0 569 79.8
Includes general medicine, hospital aged care, respiratory medicine, infectious diseases and palliative care.
Includes radiology, pathology, and other medical areas.
Includes community specialty clinic and palliative care.
§Multiple options could be selected.
||Measured on 7-point Likert scale; 1 = very unconfident, 4 = neutral, 7 = very confident.

Half of respondents reported currently working with COVID-19 patients with many more anticipating doing so in the future (Table 2). Junior doctors were significantly more likely than senior doctors to report currently working with COVID-19 patients (P < 0.001) or be furloughed (P < 0.001). Overall, hospital doctors tested positive for COVID-19 at low rates, however junior doctors were more than twice as likely to contract COVID-19 compared to seniors (P = 0.002). Despite similar access to training to care for patients with COVID-19, junior doctors were significantly less confident than senior doctors in their ability to care for these patients (P < 0.001). Over half of senior and junior doctors desired more training to use PPE and care for patients with COVID-19. While both senior and junior doctors frequently reported being concerned that their role would lead to them transmitting COVID-19 to their families, junior doctors were significantly more likely to report this concern (P < 0.001).

Moral Distress

Indicators of moral distress were high in both junior and senior doctors (Supplementary Table 1, https://links.lww.com/JOM/B63). However, compared to senior doctors, junior doctors were significantly more likely to somewhat or strongly have concerns that wearing PPE impaired their ability to care for patients (P = 0.0002), believe that if they were required to quarantine they would let down their co-workers (P < 0.001), and believe that the community was worried about healthcare workers spreading COVID-19 (P = 0.001). Two thirds of senior and junior doctors were concerned that patients would not receive the care they needed due to resource shortages, and believed that excluding families from the bedside went against their values.

Personal Relationships

Junior doctors reported significantly more adverse impacts on their personal relationships due to the COVID-19 pandemic compared with senior doctors (Table 3). Worse relationships with family (P < 0.001) and friends (P < 0.001) were significantly more likely to be reported by junior doctors, whilst senior doctors were significantly more likely to report improved relationships with family than junior doctors (P < 0.001).

TABLE 3 - Impacts on Mental Health and Personal Relationships
Senior Doctors (n = 1221) Junior Doctors (n = 745)
n % n % P
Pre-existing mental health condition diagnosed before the pandemic <0.001
 No or prefer not to say 973 79.7 539 72.3
 Yes 248 20.3 206 27.7
Subjective self-reported mental health problems experienced since COVID-19 pandemic commenced
 Anxiety 660 54.1 432 58.0 0.089
 Burnout 564 46.2 429 57.6 <0.001
 Depression 209 17.1 185 24.8 <0.001
 PTSD 46 3.8 19 2.6 0.143
 Other mental health issue 22 1.8 25 3.4 0.029
 No mental health issues 338 27.7 153 20.5 <0.001
Objective mental health symptoms assessed by validated scales
Burnout-Depersonalisation: <0.001
 None-mild 778 64.2 321 43.8
 Moderate-severe 433 35.8 412 56.2
Burnout-Emotional Exhaustion: <0.001
 None-mild 467 38.6 178 24.3
 Moderate-severe 744 61.4 555 75.7
Burnout-Personal Accomplishment: 0.011
 Low 307 25.4 225 30.7
 Moderate-high 903 74.6 508 69.3
Anxiety - GAD7 <0.001
 None-mild 994 81.4 530 71.1
 Moderate-severe 227 18.6 215 28.9
Depression—PHQ9 0.002
 None-mild 1047 85.9 599 80.5
 Moderate-severe 172 14.1 145 19.5
Impact of events/trauma–IES6 <0.001
 None-mild 839 69.0 414 55.8
 Moderate-severe 377 31.0 328 44.2
Resilience–CD-RISC-2 (mean [SD]) 3.28 (0.63) n = 1218 3.19 (0.61) n = 745 0.003
Impact on personal relationships:
Closer or stronger relationship with:
 Partner 393 32.2 248 33.3 0.613
 Family 428 35.1 140 18.8 <0.001
 Friends 150 12.3 77 10.3 0.189
 Colleagues 324 26.5 226 30.3 0.069
Worse relationship with
 Partner 154 12.6 114 15.3 0.092
 Family 167 13.7 209 28.1 <0.001
 Friends 324 26.5 310 41.6 <0.001
 Colleagues 219 17.9 137 18.4 0.800
No effect 309 25.3 134 18.0 <0.001
Burnout on the MBI is indicated by higher scores on the emotional exhaustion (EE) and depersonalisation (DP), and lower scores on the scale of personal accomplishment (PA); Burnout DP: 0–3 = low, 4–6 = moderate and 7–18 = high; Burnout EE: 0–6 = low, 7–10 = moderate, 11–18 = high; Burnout PA: 15–18 = low, 13–14 = moderate and 013 = low; IES is categorised as 0–9 = min/none and >9 = mod-severe; GAD7: 0–4 = none/minimal, 5–9 = mild, 10–14 = moderate, 15–21 = severe anxiety; PHQ9: 0–4 = none/ minimal, 5–9 = mild, 10–14 = moderate, 15–19 = moderately severe, and 20–27 = severe.

Prevalence and Predictors of Mental Health Symptoms

Self-reported mental health problems during the pandemic were common in all doctors (Table 3), with half reporting anxiety or burnout and up to a quarter reporting depression. Junior doctors were significantly more likely than senior doctors to self-report burnout (P < 0.001), depression (P < 0.001), and other non-specified mental health issues (P = 0.029). On the objective, validated mental health scales, the prevalence of symptoms of all mental illnesses was high in both junior and senior doctors. Compared to senior doctors, junior doctors were significantly more likely to experience moderate to severe symptoms of anxiety (P < 0.001), depression (P = 0.002), PTSD (P < 0.001), and burnout (moderate to severe emotional exhaustion [P < 0.001] or depersonalisation [P < 0.001], and low personal accomplishment [P = 0.011]). Resilience was generally high although, junior doctors had significantly lower resilience scores compared with senior doctors (P = 0.003).

Independent predictors of experiencing different mental illness were broadly similar for junior and senior medical staff, albeit with some variations (Fig. 1, Supplementary Tables 2, https://links.lww.com/JOM/B64 and 3, https://links.lww.com/JOM/B65).

F1
FIGURE 1:
Personal and workplace predictors of mental health symptoms in junior and senior medical staff. Predictors for junior doctors are indicated in red and for senior doctors in black. Only significant associations are shown. Bars are indicative of odds ratio (OR) with 95% confidence intervals for experiencing symptoms (on validated scales) of: (A) Anxiety, (B) Depression, (C) PTSD, and Burnout subdomains of (D) Emotional exhaustion;(E) Depersonalisation;and (F) Personal Accomplishment. For all plots (except Personal Accomplishment) OR < 1 indicate the covariate is protective, OR > 1 indicate the covariate is a predictor. Lower odds ratio for Personal Accomplishment indicate poorer outcomes. Reference categories: worse relationship with friends, family, partner, or colleagues vs no change, prior mental illness vs none, income concerns vs none, concerns of blame by colleagues vs negative response, concerns of infecting family vs negative response, female vs male, Victoria vs other states, frontline areas (ICU, medical specialty, primary care, anaesthetics and surgical) vs emergency department, PPE training vs none, age (ordinal variable), lives alone vs with others, lives with children vs does not.

Predictors for different mental health symptoms included personal factors such as: sex, living alone, worse relationships with partners, family, colleagues or friends, prior mental illness, concerns about household income and concerns about infecting family. Workplace predictors included frontline area of work, and fears of being blamed by colleagues if infected with COVID-19. Older age, living with children and receiving training to use PPE were protective factors for some mental illnesses. All other covariates examined in the univariate or multivariate models were not significantly associated with mental health symptoms.

DISCUSSION

To the best of our knowledge, this is the largest Australian study to examine the workplace, financial, social and mental health impacts of the COVID-19 pandemic on junior and senior doctors. Our results demonstrate that symptoms of mental illness and moral distress were highly prevalent in both junior and senior hospital doctors, however, junior doctors reported greater overall psychosocial morbidity. Differential personal, social, and workplace predictors of adverse mental health outcomes were identified. Disruptions to working conditions and exposure to people infected with COVID- 19 were common. However, despite both groups reporting receiving training to use PPE and care for these patients, junior doctors were significantly less confident in their ability to care for patients with COVID-19.

Differential Impacts on Working Conditions

Although work disruptions were common for both junior and senior doctors, the nature of these disruptions varied greatly by seniority. Senior hospital doctors were more likely to report working additional unpaid hours, which may reflect the fact that senior doctors often hold formal or informal leadership positions, and the pandemic generated increased coordination or management tasks. Furthermore, working additional unpaid hours may be viewed as expected and part of the cultural “norm” by doctors who often work long (unpaid) hours during training and as specialists.1 Nevertheless, the recent legal actions instituted by Australian junior doctors to challenge illegal unpaid overtime, demonstrate that junior doctors are justifiably unwilling to work unpaid hours.31 A third of senior doctors reported reducing their overall working hours and one in four had concerns about their household income. Despite also being more likely to work additional paid hours, one in five junior doctors shared these concerns. Notably, the survey referred to household income and may be reflective of loss of income from a partner or other household member working in an industry impacted by job losses, which is consistent with a quarter of the working Australian general public reducing paid hours.32 Overall, doctors fared better than other Australian frontline health workers and the general public, for whom household financial stress was higher being 30%15 and 50%,33 respectively.

Junior doctors were more likely than senior doctors to be redeployed to new work areas and were less likely to be confident in their new work areas. Although this survey did not differentiate where staff were redeployed to, these findings are reflective of concerns around training opportunities and supervision for junior doctors as a result of the pandemic.21 A systematic review of 32 papers investigating disruptions to junior doctor training in Australia during the COVID-19 pandemic identified significant impacts to career progression and attainment or duration of training requirements, citing concerns over adequate supervision.34 The potential bottlenecks in junior doctor training opportunities generated by the pandemic may have lasting implications for current and future junior doctors.

Exposure to COVID-19 Patients

Both junior and senior doctors were frequently working with, and exposed to, suspected or confirmed COVID-19 patients, though junior doctors did so at rates significantly greater than their senior counterparts. This is likely indicative of junior staff having less professional autonomy35 and working in more patient-facing settings, and echoes the trend of junior doctors being redeployed at higher rates. Professional autonomy for junior doctors is an important mediator of mental health36 and can contribute to intention to leave clinical practice.37 Although the current study did not assess intent to leave, the high prevalence of mental health issues detected in this cohort raises concerns that workplace disruptions during this time may have downstream impacts on junior doctors’ long-term desires to remain in the health workforce.

Despite having similar access to training as senior doctors, junior doctors were less confident in their ability to care for patients with COVID-19. These findings are unsurprising given that junior doctors by definition have less training and experience than senior doctors, but is a major cause for concern nonetheless. Lack of confidence in ability to care is a known risk for mental health of healthcare workers.38 A study of medical staff volunteering or working in low- or middle-income countries revealed that junior doctors were more likely to work outside their scope of training, and that doing so placed them at increased risk of moral distress.39 This was attributed, in part, to junior doctors lacking autonomy and confidence to deny requests to work beyond their scope of training.39 It is likely that junior doctors felt similarly obligated to work in settings they were not confident in during the COVID-19 pandemic, with detrimental effects on junior doctor mental health and potentially on patient safety.

Moral Distress

Both junior and senior doctors endorsed indicators of moral distress at high rates. The prevalence of both junior and senior staff reporting concerns that patient care would be compromised due to resource shortages is reflective of the strained working conditions highlighted throughout this survey. Prior studies in international healthcare worker groups have shown effectiveness in training staff to manage resources during a crisis,40 however the prolonged nature of the COVID-19 pandemic and its subsequent impact on international supply chains represents a uniquely challenging position. Junior doctors were significantly more likely to endorse concerns that PPE usage impaired their ability to care for patients with COVID-19. This specific aspect of moral distress may explain why training in PPE usage was a protective factor against development of PTSD for senior doctors but not for junior doctors. Similar concerns around ability to communicate with patients have been raised in other healthcare worker cohorts, particularly palliative care staff.41 “PPE portraits,” where healthcare workers faces are displayed on their gowns, are among attempts to humanise patient interactions and have been rated favourably by the majority of healthcare workers trialling the system.42 Simple measures such as this may be effective in protecting all medical staff from the moral distress imposed by necessary PPE usage.

Junior doctors were also more likely to endorse concerns that being required to quarantine would “let co-workers down.” Feeling like part of a team has previously been identified as the most important factor in workplace morale for junior doctors43 and loss of that sense of camaraderie due to redeployments and other interruptions to junior doctors rotations is a source of concern during COVID-19.44 Similarly, perceptions of being blamed by colleagues if infected with COVID-19 was also a common predictor of adverse mental health outcomes for both junior and senior doctors and when considered in conjunction with fear of “letting co-workers down,” may be reflective of an overstretched workforce during this time.

Increased Harm to Mental Health and Personal Relationships for Junior Doctors

The current study reported symptoms of moderate to severe mental illness ranging from 14.9% to 75.7% overall, with consistently higher prevalences detected in junior doctors. Symptoms of burnout and PTSD were particularly prevalent. Although no baseline was established in the current survey, these figures are considerably greater than previously published figures. A survey conducted in non-pandemic times reported burnout symptoms between 13% and 45%, with interns and trainees consistently experiencing greater prevalence than consultants on all three domains.45 Junior doctors in regional areas had greater prepandemic levels of emotional exhaustion (57%), yet still scored below the current study.46 Relative to those prior findings, symptoms of burnout were nearly two-fold baseline levels in the current study.

Some common predictors of poor mental health, specifically prior mental health diagnoses and younger age, are consistent with those frequently seen in the general population,47,48 whilst concerns about exposure and being blamed as risk factors are consistent with other healthcare worker cohorts during COVID-19.49,50 Increased morbidity in junior doctors relative to senior doctors is common to other healthcare workers cohorts, which indicate time in profession is inversely correlated with mental health problems.51 This is thought to be partially explained by increased resilience in more senior staff, either acquired through experience or via attrition of less resilient workers.51 Consistent with this, junior doctors in the current study scored significantly lower on measures of resilience.

Healthcare workers engaging with social supports is a known mediator of adverse mental health outcomes, particularly PTSD, in the aftermath of a crisis.52,53 Worsening of personal relationships was a common predictor of adverse mental health outcomes in both junior and senior doctors. Junior doctors were significantly more likely to report worse relationships with family and friends since the onset of COVID-19 compared to senior doctors, with the latter more likely to report closer relationships with family or no effect on personal relationships. This may be partially explained by a greater proportion of junior doctors living alone and more than half of senior doctors having children at home. Whilst parenting during COVID-19, particularly during lockdown measures, has undoubtedly placed strain on many family relationships, prior research has demonstrated a breadth of emotional responses with many parents reporting appreciation or gratitude for time spent together as a family which may buffer mental health.54 Reluctance to discuss or seek help for mental health concerns is a known concern within the medical profession and is particularly prevalent in junior doctors11,55 which may have impacted on the personal relationships of junior doctors.

Implications

Our results demonstrate that despite having high levels of resilience, junior hospital medical staff are vulnerable to excess mental health impacts during the COVID-19 pandemic. This appears to be at least in part associated with greater exposure to COVID-19 patients whilst working on the frontline of patient care. Services which target the specific needs of junior hospital medical staff are essential to ensure longevity in this workforce and deliver optimal patient outcomes.

Strengths and Limitations

Widespread distribution of the current survey prevented calculation of response rate. Selection bias may over- or underrepresent exposure to COVID-19, changes in working conditions, and impacts on mental health and moral distress. The participants in this survey, particularly junior doctors, was skewed towards (with over-representation of) female respondents. The proportion of women in the Australian medical workforce according to figures released by AHPRA and the Medical Board of Australia indicate that women make up 44% of the registered medical workforce56 and 52% of trainees.57 The current study was a single time point measure to minimise burden on healthcare workers, however longitudinal data would provide insight into changes in mental health and working conditions throughout the ongoing pandemic. At the time of writing, subsequent outbreaks have occurred resulting in short or prolonged lockdowns in NSW, SA, QLD, and WA. NSW and Victoria in particular have been impacted by a third wave driven by the Delta strain which threatens to overwhelm NSW health services, with emergency departments managing five-fold increases in presentations58 and ICU numbers surging.59 The direct impacts of these ongoing outbreaks are not reflected in the timeframe of the current study but are likely to cause ongoing harm to medical staff and warrant longitudinal investigation. Whilst redeployment was common in this cohort, no data was collected on the nature of redeployment. Further qualitative work would provide additional insight into the specific workplace disruptions described here.

CONCLUSIONS

Junior doctors are known to be at increased risk of common mental health issues, including anxiety, depression, burnout, and PTSD. This vulnerability has been exacerbated by personal and workplace factors during COVID-19. Necessary disruptions to working conditions during the COVID-19 pandemic were common for both junior and senior doctors, though junior doctors were redeployed and exposed to COVID-19 at higher rates and were less confident in their abilities in each of these domains. Both junior and senior doctors frequently endorsed indicators of moral distress resulting from pandemic conditions. Junior doctors experienced greater adverse impacts on personal relationships since the onset of COVID-19. Future efforts should focus on mediating the impacts of workforce disruptions on the careers of junior doctors as well as preventing workplace psychosocial hazards and improving active psychological supports for this at-risk cohort.

ACKNOWLEDGMENTS

We gratefully acknowledge and thank the Royal Melbourne Hospital Foundation and the Lord Mayor's Charitable Foundation for financial support for this study. We acknowledge the following people who helped plan and disseminate the survey: A/Prof Marie Bismark, ProfShyamaliDharmage, DrElizabethBarson, DrNicola Atkin, Dr Claire Long, Dr Irene Ng, Prof Anne Holland, Assoc Prof Jane Munro, Dr Irani Thevarajan, Dr Cara Moore, Assoc Prof Anthony McGillion and Ms Debra Sandford. We wish to thank the numerous health organisations, universities, professional societies, associations and colleges, and many supportive individuals who assisted in disseminating the survey. We thank the Royal Melbourne Hospital Business Intelligence Unit who provided and hosted the REDCap electronic data capture tools.

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Keywords:

COVID-19; frontline; medical staff; mental health; moral distress; occupational change

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