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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 32-40

Stress and training satisfaction among resident doctors in Nigeria: Any justification for a change in training policy?


1 Department of Psychiatry, College of Medicine, University of Lagos, Lagos State, Nigeria
2 Federal Neuropsychiatric Hospital, Abeokuta, Ogun State, Nigeria
3 Department of Psychiatry, Lagos University Teaching Hospital, Idi-Araba, Lagos-, Nigeria
4 Department of Psychiatry, College of Medicine, University of Lagos, Lagos State; Department of Psychiatry, Lagos University Teaching Hospital, Idi-Araba, Lagos-, Nigeria
5 Community AIDS Response, Johannesburg, South Africa

Date of Web Publication23-Feb-2018

Correspondence Address:
Dr. Oluseun Peter Ogunnubi
Department of Psychiatry, College of Medicine, University of Lagos, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_98_17

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  Abstract 


Background: There are pointers in existing literature to the stressful nature of residency program, thereby placing training physicians at increased risk of psychological distress. Objectives: The study identified perceived stress, its sources, training satisfaction, and the associated sociodemographic characteristics among resident doctors. Materials and Methods: A total of 405 self-administered questionnaires were given to all attendees of the National Postgraduate Medical College Revision Course. The questionnaires sought information on sociodemographic variables, sources of stress, and training satisfaction. Only 20 questionnaires were not returned. Data were collated and analyzed. Results: A majority of the respondents were male (69.1%), mostly between 31 and 35 years of age. Most (80%) of the respondents were married while 51.4% had over 4 dependents. All the respondents reported a significant level of stress, and different sources of stress were identified. Only 12 (3.1%) of the respondents were satisfied with the quality of training being received in their institutions. Conclusion: Our study found residency training to be stressful for doctors and often compounded by identifiable variables as shown in this study. Such stressful experience can, in turn, have negative impacts on their physical along with mental well-being and the patient care. Thus, there is a need for relevant stakeholders to review the structure of residency program with the view of addressing “modifiable risks” of stress among would-be specialists.

Keywords: Nigeria, perceived stress, residency training, satisfaction


How to cite this article:
Ogunnubi OP, Ojo TM, Oyelohunnu MA, Olagunju AT, Tshuma N. Stress and training satisfaction among resident doctors in Nigeria: Any justification for a change in training policy?. J Clin Sci 2018;15:32-40

How to cite this URL:
Ogunnubi OP, Ojo TM, Oyelohunnu MA, Olagunju AT, Tshuma N. Stress and training satisfaction among resident doctors in Nigeria: Any justification for a change in training policy?. J Clin Sci [serial online] 2018 [cited 2022 Oct 2];15:32-40. Available from: https://www.jcsjournal.org/text.asp?2018/15/1/32/226046




  Introduction Top


Medical residency training period is pivotal to becoming certified physician and universally associated with high levels of physical and emotional demands.[1],[2] For instance, residents have to cope with increased responsibility and workload, sleep deprivation, physical exhaustion, and low wages.[3],[4] During this time, residents have to learn how to use their time efficiently, acquire the necessary knowledge and technical skills to perform at a high level, and develop empathy and compassion for the medically ill. The residency training program provides frequent exposure to death and dying, producing a great deal of anxiety and self-doubt.[5] Consequently, medical residency training can be a time of high stress and may contribute to feelings of burnout, distress, and depression.[6]

The reported prevalence of burnout is highly variable among resident doctors, ranging from 18% to 82%,[7],[8],[9] and the prevalence of depressive symptoms in residents has been estimated to range from 7% to 56%.[10],[11],[12] This variability can be attributed to small samples, different measurement instruments, and methodological shortcomings in most studies.[1],[2]

Work stress and burnout remain significant concerns in medical profession, affecting both individuals and organizations. For the individual doctor, regardless of whether stress is perceived positively or negatively, the neuroendocrine response yields physiologic reactions that may ultimately contribute to illness.[13] In the health-care organization, work stress may contribute to absenteeism and turnover, both of which detract from the quality of care.[14] In Nigeria, for example, the demand for acute care services may be said to be increasing concurrently with changing career expectations among potential health-care workers and growing dissatisfaction among existing hospital staff. Studies have explored work stress among health-care personnel in many countries.[15],[16] Investigators have also assessed work stress among medical technicians,[17] radiation therapists,[18] social workers,[15] occupational therapists,[19] physicians,[20] and collections of health-care staff across disciplines.[21]

Stress has been regarded as an occupational hazard since the mid-1950s.[22] In fact, occupational stress has been cited as a significant health problem.[23] Existing medical education programs reflect models of work stress and burnout focused on resident doctors;[24] at the same time, they fail to incorporate aspects of the residents' social support systems as well as the multiple components of holistic wellness models. Given that multiple studies during a 10-year period reveal that residents are tired and overwhelmed, are afraid of making mistakes, and have little or no time for anything or anyone other than their training,[25] attentions to holistic and interpersonal factors affecting their well-being are needed and timely, if not overdue.

The identified sources of stress among doctors from literature have been patient care, decision-making, taking responsibility, and change.[14] Since the mid-1980s, however, doctors' work stress may be escalating due to the increasing use of technology, continuing rises in health-care costs,[14] and turbulence within the work environment.[26] Stress may result from the combined responsibilities of work, marriage, and children.[27]

Although there has been increased attention on the well-being of medical residents, literature on residents' psychological profiles and stress is relatively limited.[1],[2] It is hoped that by surveying doctors undergoing residency training in Nigeria, there will be better knowledge on current stressors affecting residents and improve residency training on a state/national level.


  Materials and Methods Top


Study setting

This was a descriptive cross-sectional study conducted among attendees of a revision course organized by the National Postgraduate Medical College of Nigeria (NPMCN). The NPMCN is one of the two postgraduate medical colleges in Nigeria established in 1974 through an act of the Parliament of the Federal Republic of Nigeria and saddled with the responsibilities of training medical doctors and dentists undergoing specialization in the country (NPMCN).[28] The another postgraduate medical college is the West African College of Physicians and Surgeons. Each of these colleges trains doctors in different areas of specialization such as obstetrics and gynecology, internal medicine, surgery, pediatrics, pathology (morbid anatomy, hematology, and microbiology), community health, psychiatry, radiodiagnosis, physiotherapy, ophthalmology, dentistry, and biomedical sciences. There are three main stages of examinations that residents have to take in order to become full specialists/consultants. These are the primary examination which qualifies them to start residency training in their chosen fields, the Part 1 examination which they take after 2–3 years of junior residency and the final Part 2 examination which they take after 2–4 years of passing part 1 and working as senior registrars. It is upon the completion of the Part 2 examination that they are awarded the fellowship of any of the respective college. The rules and the duration of training for each specialization are determined from time to time by these postgraduate colleges. The week-long revision course is usually a prerequisite for sitting for either Part 1 or 2 examinations of the college and usually held annually.

Study population

The study population was made up of medical and dental doctors currently undergoing residency/specialization training from all the teaching and residency training hospitals/centers in Nigeria who attended the National Postgraduate Medical College's Revision Course.

Following ethical approval, 400 questionnaires were given out to consenting resident doctors who attended the course. Apart from those that gave informed consent, being a full resident doctor and undergoing training within Nigeria were criteria for inclusion into the study while those training as supernumerary or in other neighboring West African countries were excluded as they are usually not subjected to the same residency factors, such as remuneration, conditions of service, or working hours.

Study instruments

A designed questionnaire enquired about the sociodemographic information of the participants, such as age, sex, marital status, educational level, family background and number of dependent relatives, types of training centers, duration of training, and specialization area. The designed questionnaire also enquired about the subjective experience of the participants during their residency training, such as associated stress (if any), sources of these stress, and their satisfaction with residency training.

Ethical approval

Approval and permission were sought and obtained from the course coordinator on behalf of the National Postgraduate Medical College and from the Lagos University Teaching Hospital-Health Research Ethics Committee (LUTH-HREC Number ADM/DCST/HREC/APP/1562). Likewise, written informed consent was obtained from each participant after detailed explanation about the aims and objectives of the study by the researcher. Nonreturn of the questionnaire by any of the participants was also taken as evidence that consent was not given. Strict attention was paid to protecting the identity of the participants and information given was treated with absolute confidentiality.

Data collection procedure and analysis

Participants who met the inclusion criteria were given the designed self-administered questionnaire. Each questionnaire booklet had a serial number for easy computation. The questionnaires were collected back after they had been filled and information yielded by each was subsequently analyzed. Means, frequencies, and percentages were used to analyze the data and use of frequency tables and charts were applied where necessary.

Comparison between categorized sociodemographic attributes and satisfaction with residency training was done by Chi-square test.


  Results Top


Sociodemographic profile of participants

Of the 400 questionnaires given out, 385 were returned, translating to a response rate of 96%. [Table 1] shows that majority of the age groups were between 25 and 49 years. About 7 in 10 (69.1%) of the respondents were male. About 80.8% of the respondents were married, while three-quarter (74%) of them had a monogamous family background. Slightly more than half (51.4%) of the respondents had over 4 dependents while 11.2% had none. Majority of the respondents were Christians, representing 78.7% of the respondents. The respondents were interspersed into different major ethnic groups in Nigeria, with majority being of the Yoruba tribe (34.8%).
Table 1: Sociodemographic profile of participants (n=385)

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Residency training profile of the participants

Majority of the participants (56.1%) started residency training between 3 and 5 years after graduating from medical school [Table 2]. Only 3.4% of the participants had their training centers located in the northeastern part of the country. While 31.9% of the participants are in internal medicine specialty, those in dentistry were the least (1.6%). Most of the participants were from teaching hospitals (84.7%). About 11.9% of the participants were training in centers where there was no policy in place as to the total duration of residency training before being asked to exit the program. Majority of the respondents (55.3%) worked 26–50 h/week on the average. The senior registrars constituted 99% of the study participants.
Table 2: Training-related characteristics of the participants (n=385)

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Training satisfaction levels among the participants

Only 126 (32.7%) of the participants were satisfied with the training they were receiving in their training institutions, while a large proportion (89.6%) of the participants were not satisfied with residency training in Nigeria as a whole [Table 3].
Table 3: Training satisfaction levels among the participants

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Relationship between sociodemographic attributes and satisfaction with residency training

[Table 4] shows the relationship between the sociodemographic profile of the participants and their satisfaction with residency training. The significant variables that were associated with training satisfactions are age (χ2 = 17.623; P = 0.005), family background (χ2 = 7.797; P = 0.006), religion (χ2 = 10.771; P = 0.003), and tribe (χ2 = 27.803; P < 0.001).
Table 4: Relationship between sociodemographic attributes and satisfaction with residency training

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Relationship between training-related attributes and satisfaction with residency training

[Table 5] shows the relationship between the training-related attributes of the participants and their satisfaction with residency training. The significant variables that were associated with training satisfactions are number of years postgraduation (χ2 = 16.127; P = 0.001) and geopolitical location of the training institution (χ2 = 42.057; P < 0.001).
Table 5: Relationship between training-related attributes and training satisfaction

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Residency training and associated stress among the participants

All the respondents (100%) considered residency training period as stressful [Figure 1] as they all chose outside the “0” in the adapted version of the perceived stress questionnaire.
Figure 1: Perception of stress associated with residency training

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Sources of stress among the participants

[Figure 2] and [Figure 3] describe the various sources of stress among the participants.
Figure 2: Distribution of the mean stress level since commencement of residency training. Key: Resstruc = Residency structure

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Figure 3: Distribution of the mean stress level since commencement of residency training. Key: Resstruc = Residency structure; Prelationship = Personal relationship; PFsafety = Personal and family safety; Timepres = Time pressure. (Where 0.0000 is none and 3.5000 is the severe stress)

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  Discussion Top


Medical residency in Nigeria is more than 40 years old.[29] Residents are expected to play the role of a competent and caring physicians-in-training, focusing on their studies and investing their time, knowledge, and passion in the practice. However, the original idea of protected education of future physicians has evolved into a different reality as stress is sometimes considered part of the rite of passage from student to physician. In this study, all resident doctors perceive their residency training as stressful, although sources of these perceptions differ among gender. This is in keeping with most of the studies earlier done in this regard. For example, Issa et al. in Ilorin, Nigeria,[30] studied stress in residency training as perceived by resident doctors in a Nigerian University Teaching Hospital. They found that 69 out of the total 73 resident doctors, representing 94.5% of the study group, perceived residency training period as stressful.[30] Interestingly, their study showed more of the junior residents perceiving residency period as stressful, while they cited Cohen and Patten's study in 2005 which posited that low experience level might lead to increased stress and increase reporting of stress among junior resident doctors.[31] This present study however contradicts this assertion as almost all the study participants are senior residents, yet they all (100%) perceived residency period as stressful. A finding which then suggests that just as junior resident doctors have their own stress factors, ditto for their senior counterparts. Such stress factors include examination and workload. Studies have similarly reported increased stress and burnout among resident doctors [8],[32] and as reported by Martini et al. in 2004 that the early part of residency is an independent factor contributing to burnout with a call for policy changes targeting that particular year of training.[8] Thus, as posited also by Issa et al., in 2005, measures aimed at reducing stress at this level might have the highest impact on its reduction, thereby contributing to the promotion of healthier academic and clinical environments.[30]

This study did not find any significance in gender with regard to perception of residency training, as both genders perceived it as stressful, this is in contrast with the study of Gautam in 2001, where it was noted that there were some stressful factors peculiar to females and thus reported that female doctors were more stressed than males.[33] The between study differences in methodology and performance of similar duties by residents across specialty fields irrespective of gender might explain why a gender difference in relation to stress was not found in this report.

This study reveals the major sources of stress to be work situation, structure of residency training, and discrimination, a finding similar to the study by Ogunsemi et al., in 2010.[34] This however slightly differs from the study of Issa et al., 2005, where they found that about three-fourth of the respondents thought frequent examination, and more than four-fifth of them thought high clinical workload was a cause of their stress,[30] a similar finding that has been reported by the earlier study of Schwartz et al.[35]

A significant number of the residents (55.3%) work for 26–50 h/week. High workload, sleep deprivation, and poor financial remuneration were some of the factors recognized in our study as stressors in residency education. Existing literature has linked high workload, juggling multiple roles and man-power shortage with increased stress among resident doctors.[36] Similar concerns about workload were expressed in an earlier study among medical students.[37] Workload is thus considered a significant source of stress for these residents, a major reason why the Accreditation Council for Graduate Medical Education (ACGME), for example, in 2003, in the United State of America implemented regulations on duty hours, limiting them to <80 h/week (ACGME). The objectives of the regulation were to improve resident doctors' education and quality of life and to provide patients with optimal care.[38],[39] As found in this study, the average working hours of majority of the resident doctors appear to be within the approved government regulation obtained in developed nations such as the United states of America where the resident doctors have been limited to working no more than 80 h/week, i.e., in-house call can be no more frequent than every third night and 24-h shifts must be followed up by at least 10 h free of clinical duties.[40] Depending on the schedule of various units, rest in the form of leave is beneficial in the long run, as fatigue from overwork invariably can lead to lower productivity and increase the risk of errors and adverse events.[41]

Almost three-quarter of the respondents were not satisfied with the training they were receiving in their various institutions and even a larger percentage showed dissatisfaction with residency training in Nigeria as a whole. This is similar to the findings of Issa et al. in 2007 in their study among 73 consenting resident doctors in University of Ilorin Teaching Hospital.[30] Studies have also linked satisfaction on job performance and absenteeism;[42],[43],[44] hence, dissatisfaction of resident doctors with the training they are receiving may go a long way in determining their effectiveness to their work as well as the quality of specialist doctors they will be in future. According to the respondents, some of the factors leading to their dissatisfaction are remuneration, work situation, examination, structure of residency training, discrimination from senior colleagues, and time pressure among other factors. Studies have shown the impact of remuneration on job performance.[45],[46] This can be improved upon as it will serve as an incentive to attract many young doctors into the program. With regard to intimidation, this result is consistent with the studies examining resident bullying.[47] Consultants as team leaders should also use their abilities as teachers, role models, and mentors to positively influence the residents as earlier proposed by de Jong.[48] The provision of an environment conducive for learning, educational aids, journals, improved funding, and establishment of more training centers will go a long way in addressing the complaints of resident doctors.

In ameliorating the stress associated with the examination, it is noteworthy that the NPMCN for example has started decentralizing the examinations at the primary and Part 1 level, for some time now. Effectively decentralizing the examinations at all levels will go a long way to improve the satisfaction level of the would-be specialists, though such move will require more examiners, more funds, and more training centers; it is expected that the Government of Nigeria should support such move.

With regard to policy on residency training for example, resident doctors used to travel overseas for a year clinical training which is fully sponsored by the government. But that has since stopped on the excuse of government's inability to fund the policy. This elective posting had helped bridge the gap between the training received here and that learned abroad. It had also offered the residents the opportunity to observe and practice medicine at the best of centers. The benefits of this cannot be overemphasized.[29]

None of the earlier literature reviewed focused on the association between sociodemographic profile of resident doctors and their satisfaction with residency training. Likewise, none focused on finding out the association between residency training attributes and satisfaction with training. Our findings thus revealed that age, family background, religion, tribe, geopolitical location of the training institution, and the number of years postgraduation were the variables that were significantly associated with the level of satisfaction with residency training among the participants.

There is overrepresentation of older age group among those with residency training satisfaction, thereby suggesting improved coping skills and realistic expectations as people get older.

There is overrepresentation of Yoruba tribe among the satisfied group, while being from Hausa tribe was associated with higher level of dissatisfaction with training among the participants. This may be because most of the residency training centers are located in the South-West, likewise the national offices of the two postgraduate medical colleges. In addition, the examination centers of the two postgraduate medical colleges are both located in Ibadan and Lagos, which are cities in the southwestern part of the country with predominance of Yoruba-speaking people. This could have given the residents in these areas an advantage over their other colleagues in other parts of the country. The same pattern was found as geopolitical zones where residency training institutions are situated were associated with the level of satisfaction among study participants. The number of years post-graduation before residency training was significantly associated with satisfaction level. It could be that participants with longer duration before starting residency training tend to appreciate the training better than those who got in easily without any delay.


  Conclusion and Recommendations Top


This study found a high level of stress and dissatisfaction with residency training. This is consistent with the other published findings from studies addressing burn out among resident doctors and the factors responsible for it. To address these problems, there is a need to restructure the residency training policy viz-a-viz improved allocation of resources toward the training and strict policy on remuneration and hours of work. This can be best achieved through the establishment of residency training board which will be saddled with the responsibility of regulation residency training in Nigeria.

There is a need for future studies to employ the use of international standardized instruments to measure “stress” and “level of satisfaction with residency training” among this group of people to generalize the findings of such studies.

Limitation and strength

The use of standardized structured diagnostic instrument in measuring “stress” would have helped increase the reproducibility of this study.

However, despite the aforementioned limitations, the strengths of this study lie in the large number of samples used – a scientific representative of the resident doctors in Nigeria as a whole. More so is the fact that the study participants comprise representatives in all the 6 geopolitical zones of the country. These two factors allow for generalizability of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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