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

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

The Impact of Changes in Mental Health Legislation on Psychiatry Trainee Stress in Victoria, Australia.

In Victoria, Australia, the introduction of a new state Mental Health Act (MHA) in 2014 resulted in changes to the workload and type of work undertaken by trainee psychiatrists. In addition to long working hours, workload intensity is most often cited by trainees as a factor that leads to fatigue, with trainees often taking work home or doing overtime in order to fulfill work responsibilities and satisfy training requirements. This administrative burden is compounded by the high emotional burden associated with the practice of psychiatry, including patient suicides, aggression, and threats. This study aimed to explore the impact of these legislative changes on psychiatry trainees' stress and well-being, using a qualitative research methodology involving semi-structured interviews. Despite reporting that the length and number of reports they were preparing under the new MHA had increased, as had the amount of time spent at Tribunal hearings, psychiatry trainees were understanding of the necessity of MHA changes in improving patient rights. The trainees did not express a desire for the MHA changes to be reversed, but rather recognition by their workplaces that changes are also needed at a ground level-such as an increase in staff numbers-to accommodate for these. While mental health legislative changes are designed to improve the system and better protect patient rights, measures must also be taken to ensure that any policy-level changes are adequately adjusted for in hospital staffing levels.

Psychotropic medication deprescribing in residential aged care facilities: An exploratory study of the knowledge and attitudes of family members of residents with dementia.

OBJECTIVES: General practitioners face many barriers to deprescribing psychotropic medications in people with dementia in nursing homes, including a lack of knowledge about their medication histories. This study explored the knowledge of family members about residents' medications and their willingness to support deprescribing. METHODS: Sixty-six family members of residents from seven residential aged care facilities participated in this cross-sectional study. Participation involved nomination of recognised medications, rating their effectiveness and rating level of support for deprescribing. RESULTS: Fifty-five per cent of medications were recognised by family members; significantly fewer psychotropics were recognised than non-psychotropic medications. Though rated as just as effective, support for deprescribing psychotropics was significantly higher. Most family members were agreeable to deprescribing with general practitioner support. CONCLUSIONS: Although there is a gap in family members' knowledge about psychotropic medications, overall they are supportive of deprescribing. Findings emphasise the need for psychoeducation among family members. Providing family members with a list of prescribed medications, specifying the type of and reason for prescription and side effects of each, is recommended to facilitate their advocacy for deprescribing on behalf of nursing home residents.

Stress and Wellbeing of Psychiatry Trainees: A Literature Review.

Medical training in Australia has been clouded in recent times by media reporting on the tragic suicides of multiple trainees. This has brought attention to the stressful demands of the medical profession and the often-poor wellbeing of trainees, who must balance both study and work demands. Psychiatry trainees in particular face unique stressors in the workplace, being in a profession that carries a high emotional burden. Psychiatry trainees encounter suicides by patients and colleagues at an alarmingly high rate and commonly experience isolation, unrealistic workloads and stigma towards their chosen specialty. This literature review will highlight the extent to which these factors impact on psychiatry trainees. We will also explore the factors that contribute to their wellbeing, including the role of supervision, as well as leisurely and social activities. This review will look at the availability of these supports to psychiatry trainees and whether their lifestyles allow them time to spend on these activities. Though it is impossible to remove all stressors from psychiatry, interventions to improve trainee wellbeing must consider factors that improve resilience and support as well as target change to the culture in medicine that currently promotes stress and overwork. It must be recognised that trainees who feel supported and mentally well will perform better in the workplace in the long run, and, in this review, we will speculate about how workplace changes that are occurring for psychiatry trainees in Victoria, Australia, may affect their wellbeing.

Quality indicators of psychotropic prescribing to people with dementia in aged psychiatry inpatient units.

OBJECTIVES: To develop indicators of safe psychotropic prescribing practices for people with dementia and to test them in a convenience sample of six aged mental health services in Victoria, Australia. METHOD: The clinical records of 115 acute inpatients were checked by four trained auditors against indicators derived from three Australian health care quality and safety standards or guidelines. Indicators addressed psychotropic medication history taking; the prescribing of regular and 'as needed' psychotropics; the documentation of psychotropic adverse reactions, and discharge medication plans. RESULTS: The most problematic areas concerned the gathering of information about patients' psychotropic prescribing histories at the point of entry to the ward and, later, the handing over on discharge of information concerning newly prescribed treatments and the reasons for ceasing medications, including adverse reactions. There were wide variations between services. CONCLUSION: The indicators, while drawn from current Australian guidelines, were entirely consistent with current prescribing frameworks and provide useful measures of prescribing practice for use in benchmarking and other quality improvement activities.

Psychodynamic Leadership Approach and Leader-Member Exchange (LMX): A Psychiatric Perspective on Two Leadership Theories and Implications for Training Future Psychiatrist Leaders.

An increased emphasis in recent years on psychiatrists as healthcare leaders has not only drawn attention to the skills they can bring to this role but has also raised questions about how to best train and prepare them to assume leadership responsibilities. Such training should not be conducted in isolation from, and oblivious to, the wide-ranging expertise in human behaviour and relationships that psychiatrists can bring to the leadership arena. The aim of this theoretical paper is to draw attention to how psychiatrists can use their existing knowledge and skill set to inform their understanding of leadership theory and practice. In particular, the Psychodynamic Leadership Approach and Leader-Member Exchange theory are compared and contrasted to illustrate this point. The former represents a less well-known approach to leadership theory and practice whereas the latter is a widely familiar, conventional theory that is regularly taught in leadership courses. Both are underpinned by their emphasis on leader-follower relationships-and human relationships more broadly-and are intuitively appealing to psychiatrists endeavouring to understand aspects of organisational behaviour in the healthcare settings in which they work and lead. The application of these theories to assist reflection on and understanding of professional and personal leadership behaviours through leadership-oriented Balint-style groups and 360-degree appraisal is proposed. It is hoped that this paper will serve to stimulate thought and discussion about how leadership training for future psychiatrists can be tailored to better harness their existing competencies, thereby developing richer formative learning experiences and, ultimately, achieving superior leadership outcomes.

Objective Structured Clinical Examination (OSCE) in Psychiatry Education: A Review of Its Role in Competency-Based Assessment.

Over the last two decades, Objective Structured Clinical Examination (OSCE) has become an increasingly important part of psychiatry education and assessment in the Australian context. A reappraisal of the evidence base regarding the use of OSCE in psychiatry is therefore timely. This paper reviews the literature regarding the use of OSCE as an assessment tool in both undergraduate and postgraduate psychiatry training settings. Suitable articles were identified using the search terms 'psychiatry AND OSCE' in the ERIC (educational) and PubMed (healthcare) databases and grouped according to their predominant focus: (1) the validity of OSCEs in psychiatry; (2) candidate preparation and other factors impacting on performance; and (3) special topics. The literature suggests that the OSCE has been widely adopted in psychiatry education, as a valid and reliable method of assessing psychiatric competencies that is acceptable to both learners and teachers alike. The limited evidence base regarding its validity for postgraduate psychiatry examinations suggests that more research is needed in this domain. Despite any shortcomings, OSCEs are currently ubiquitous in all areas of undergraduate and postgraduate medicine and proposing a better alternative for competency-based assessment is difficult. A critical question is whether OSCE is sufficient on its own to assess high-level consultancy skills, and aspects of professionalism and ethical practice, that are essential for effective specialist practice, or whether it needs to be supplemented by additional testing modalities.

Programmatic Assessment of Professionalism in Psychiatry Education: A Literature Review and Implementation Guide.

Programmatic assessment is being adopted as a preferred method of assessment in postgraduate medical education in Australia. Programmatic assessment of professionalism is likely to receive increasing attention. This paper reviews the literature regarding the assessment of professionalism in psychiatry. A search using the terms 'professionalism AND psychiatry' was conducted in the ERIC database. Only original articles relevant to professionalism education and assessment in psychiatry were selected, rather than theoretical or review papers that applied research from other fields of medicine to psychiatry. Articles regarding the need for professionalism education in psychiatry were included as they provided a rationale for curriculum development in this field as a precursor to assessment. Key findings from the literature were summarised in light of the author's own experience as an educator and assessor of both medical students and trainees in psychiatry, and incorporated into a guide to implementing programmatic assessment of professionalism in psychiatry. Within psychiatry, the specific evidence base for use of particular tools in assessing professionalism is limited. However, used in conjunction with psychiatrists' views about what is important in professionalism education, as well as knowledge from other medical disciplines regarding professionalism assessment tools, this evidence can inform implementation of programmatic assessment of professionalism in undergraduate, postgraduate and continuing professional development settings. Given the emergent nature of such assessment initiatives, they should be subjected to rigorous evaluation.

Clinical Simulation Training in Geriatric Medicine: A Review of the Evidence and Lessons for Training in Psychiatry of Old Age.

Clinical simulation encompasses a broad range of methods and techniques that allow clinical skills to be rehearsed and practiced away from the clinic before being applied to real patients. As such, preparation of doctors and other healthcare professionals for safe clinical practice is one of its main aims. The objective of this paper was to review the evidence regarding the use of clinical simulation training in geriatric medicine education and consider how the findings may be translated to education in the closely related field of psychiatry of old age. Original papers and descriptive case studies of clinical simulation training programs for medical professionals were considered for inclusion. Papers were grouped according to the participants' level of training: (1) undergraduate medical education; (2) postgraduate medical education; and (3) multiple levels of medical learners. A diverse range of effective simulation modalities for teaching geriatric medicine was identified across all levels of learning. The evidence suggests that there is much fertile ground for trainees in geriatric medicine and psychiatry of old age to participate in joint simulation training programs, thereby maximising their reach while minimising associated resource requirements and financials costs. Given the prominent position of psychiatry of old age at the interface between psychiatry and medicine, old age psychiatrists potentially have much to offer in advancing the field of clinical simulation while simultaneously improving patient care.

Alfentanil anesthetic augmentation lengthens seizure duration in electroconvulsive therapy with older people.

Electroconvulsive therapy (ECT) prescription rates rise with age, making it important that treatments be made as effective and safe as possible (Plakiotis et al., 2012). Older people are vulnerable to post-treatment confusion and to subsequent deficits in attention, new learning, and autobiographical memory (Gardner and O'Connor, 2008). Strategies to minimize cognitive side-effects include unilateral electrode placement and stimulus dose titration whereby electrical charge is individually calibrated to seizure threshold (Sackeim et al., 2000). It remains the case, however, that threshold levels typically rise over the treatment course, leading to an increase both in delivered charge and the risk of adverse sequelae.

The Clinical and Service Outcomes of Unilateral and Bilateral ECT Electrode Placements in Australian Aged Psychiatry Services.

OBJECTIVE: The aim of the study was to determine whether depressed aged inpatients treated with brief pulse unilateral electroconvulsive therapy (ECT) differed from those treated with bilateral (bitemporal or bifrontal) ECT with respect to numbers of treatments, length of hospital admission, changes in scores on depression and cognitive scales, and serious adverse effects. METHODS: An audit of routinely collected data regarding 221 acute ECT courses in 7 public aged psychiatry services in Victoria, Australia. RESULTS: Patients given unilateral, bifrontal, and bitemporal treatments were similar with respect to personal, clinical, and treatment characteristics. Most treatments were administered in line with local clinical guidelines and were rated as effective. Psychiatrists preferred unilateral ECT in the first instance with stimulus dosing based on patients' seizure thresholds. Approximately a quarter of unilateral courses were switched later to bitemporal placement, most probably because of insufficient progress. Bilateral treatments were associated with a larger number of treatments, less improvement in scores on mood and cognitive scales, and more refusals to continue treatment than unilateral-only ECT. DISCUSSION: Brief pulse unilateral ECT proved more effective than bitemporal and bifrontal ECT for most aged patients, especially when coupled with stimulus dosing based on seizure threshold.

Deprescribing psychotropic medications in aged care facilities: the potential role of family members.

There is widespread concern in Australia and internationally at the high prevalence of psychotropic medication use in residential aged care facilities. It is difficult for nurses and general practitioners in aged care facilities to cease new residents' psychotropic medications when they often have no information about why residents were started on the treatment, when and by whom and with what result. Most existing interventions have had a limited and temporary effect and there is a need to test different strategies to overcome the structural and practical barriers to psychotropic medication cessation or deprescribing. In this chapter, we review the literature regarding psychotropic medication deprescribing in aged care facilities and present the protocol of a novel study that will examine the potential role of family members in facilitating deprescribing. This project will help determine if family members can contribute information that will prove useful to clinicians and thereby overcome one of the barriers to deprescribing medications whose harmful effects often outweigh their benefits. We wish to understand the knowledge and attitudes of family members regarding the prescribing and deprescribing of psychotropic medications to newly admitted residents of aged care facilities with a view to developing and testing a range of clinical interventions that will result in better, safer prescribing practices.