Theme 1: well-being strategies implemented by junior doctors

Most junior doctors reported exercise as a beneficial strategy for physical and mental well-being. The types of exercise varied from regular, shorter activities such as cycling, gym, high-intensity interval training and walking, and those less frequent, typically longer forms of exercise, such as hiking and bouldering. The reported benefits of exercise included improvement in sleep, providing an emotional outlet and a social event in the case of team sport.

Exercise helps me to focus and makes me happy because I'm doing something with my body, and obviously the endorphins are being released … achieving goals and targets … make me really happy as well and give me the encouragement to be able to do other things [D6, female].

Some junior doctors reported a healthy, balanced diet to be beneficial to provide energy and improve physical and mental well-being. Meal prepping and consciously being aware of eating and drinking water while on a shift were part of this strategy. This awareness at work extended to taking breaks as short as five minutes.

When I actually manage to eat regularly and drink water, especially when I'm working, it really helps me get through that shift [D8, female].

Maintaining connections with family and friends, particularly those outside of medicine, was reported as very important by most participants. Social activities build a sense of community and fun activities are an outlet. Social activities with colleagues were also reported as vital due to the common understanding of the challenges of being junior doctors. Informal gatherings with colleagues to discuss issues and listen to each other also increases connection. The ability to connect and communicate with other junior doctors, allows them to feel less isolated with the problems that they may be facing. This in turn can effectively improve junior doctors’ mental health.

It doesn’t have to be a formal thing. It’s just having the opportunity to ask others how they are going and listening to them when they're having a problem [D6, female].

A handful of junior doctors reported having a supportive partner with whom they could openly discuss mental health and communicate deeper feelings often not discussed with friends. Partners also provide accountability with routines. One participant felt that they lost a ‘major pillar of support in [their] life’ when they lived in different states than their partner.

If I'm feeling stressed, I'll try and talk to my partner. … Having a supportive partner definitely helps … to do the meal prep and actually have a good routine [D13, male].

Having hobbies outside of work was an important strategy for many junior doctors. Podcasts, and music, as well as video games which had a social aspect, were the most popular online activities. Common offline activities included chess, reading and outdoor activities such as camping and fishing.

It’s not each individual thing is going to help but just having a variety of interests and activities. So that you’re not just going to work and coming home and doing nothing else [D7, female].

There were multiple mental well-being strategies identified by junior doctors. Getting enough sleep allows for proficiency at work. Practising mindfulness regularly, especially when encountering a difficult situation at work, can be useful in setting a positive mindset to continue the day’s work. It also reduces the likelihood of poor experiences with patients or colleagues from affecting one’s work ethic for the rest of the day. Meditation was also reported by some junior doctors as beneficial to mental well-being.

I think it’s good to just take a break and clear the mind for a little bit and be on your own and just reflect on whatever it is that’s challenging you [D6, female].

If I'm at that high stress level at work, I kind of just do a little check in of like, “okay, you're really stressed, that’s okay. You just need to breathe. Everything will be okay [D15, female].

Similarly, setting realistic expectations was identified as a key enabler of junior doctors’ well-being. In addition, prioritising and compartmentalising work-related and personal tasks helps reduce the chances of feeling overwhelmed.

I guess one of the hardest things is trying to…set realistic expectations yourself [B1, male].

You need to sit there and physically stop and say to yourself what actually needs to be done right now and what doesn't and what can we wait till tomorrow or later in the week. The busier you are, the more you need to actually slow down and stop and take a breath and actually see what’s going on, reprioritize and get going again [B1, male].

In addition, there were several beneficial well-being strategies identified within the workplace. A key strategy identified was debriefing with colleagues after encountering challenging situations. This allows junior doctors to share their feelings freely and comfortably, while gaining insight into the way their other colleagues feel or may handle a similar situation in the future. Junior doctors reported it useful to have a senior doctor who is vulnerable and shares their own experiences with self-care and coping with the trying lifestyle of a doctor.

I've had consultants say “that last patient you had was really stressful. Don't pick up another patient. Go take a break. Don't push yourself too hard. You just dealt with something very traumatising. You need to go and take 30 minutes … then come back.” I feel like it’s something that’s really well understood, and easy to talk about between colleagues [D15, female].

Lastly, the establishment of organisations such as Junior Doctor Societies within hospitals can encourage junior doctors to interact with their peers within the hospital and develop a support network of junior doctors.

Junior Doctors Society has a free lunch once every couple of weeks or so, and there’s a bit of reminder … even if you only come and grab something, take 5 minutes out, actually have some food, have something to drink and carry on [B1, male].

There were a small number of strategies mentioned by participants that have been identified as outliers. These include smoking cigarettes and consuming alcohol daily to cope with the stress of work as a junior doctor, and consuming sugary beverages during shifts to stay alert. Religious practice was mentioned by one participant as an important mental health strategy. Additionally, one participant reported that the work–life balance when working in a rural hospital is much better due to the reduced workload.

Theme 2: barriers to well-being and using well-being strategies

Many of the barriers to well-being identified by junior doctors were identified within the workplace.

A high workload is a significant cause of stress for junior doctors, and working long hours is tiring. Working overtime reduces the time available to consolidate learning and teaching during a shift, and limits time for sleep and self-care.

I think the biggest challenge is the workload. [D7, female].

Planning and routine is important for self-care but is impacted by short notice changes to rosters and overtime shifts. Inconsistent shifts, particularly evident in emergency rotations, make it very difficult to maintain a regular schedule which would enable more well-being strategies.

(Lack of) time and lack of routine can be hard … even if you have a lot of time, your routine is unpredictable. You're going to work a night shift, and then you might work a day shift and you might work a half day. It throws out everything, because you don't have consistency in your routine [D2, female].

Furthermore, there is a fear of claiming overtime due to the opinion of senior staff, as well as inconsistent payment of overtime between hospitals and between departments and teams of the same hospital. This reduces the incentive to work overtime, despite the pressure to do so.

I feel that overtime is an issue at each hospital… I guess everyone does overtime. It is whether we submit it to be paid for it or not … there’s a bit of a culture of you just sort of ask one of the senior doctors if they will pay overtime or not [D10, male].

The lack of flexibility of leave (ie, having to take five weeks at once) and part-time work as a junior doctor not being an option, is a further barrier to well-being.

It’s very hard to work part time as an intern. I have no intention of wanting to work part time, but for example, people trying to have a family or things like that, there’s no option to do your internship part time [D10, male].

Inexperience is also unavoidable as a junior doctor. However, junior doctors carry a significant burden of responsibility, with little guidance on how to deal with it. Junior doctors often lack familiarity with the healthcare and computer systems, in addition to pressure from nurses to have answers, and the generally high expectations of knowing everything.

You get asked so many questions, especially by nursing staff and you are expected to know a lot of the answers which you may not necessarily know because you're only a junior … so sometimes you have to fake it till you make it [D6, female].

Some of the common stressors within the workplace experienced by junior doctors include becoming familiarised with the administrative processes of each department or hospital, the concern of harming patients, and the desire to be a safe junior doctor. Additionally, junior doctors are often faced with completing numerous menial tasks which can compound, contributing to overtime.

I think a lot of stress that we find as junior doctors isn't necessarily related to the biomedical things. A lot of it is actually just administrative processes that create a lot of sort of angst … What forms do I need to do? Where are they physically to be found? These are administrative, bureaucratic processes, and once you know them, they're very easy [D1, male].

It’s a cultural thing, the fact that they (senior doctors) have you doing all of the work, like all of the notes and all of the referrals and all of that sort of thing which they are perfectly capable of doing. But I guess the culture is that the younger, junior doctors do all that [D10, male].

Several junior doctors reported that bullying is accepted as a normal part of certain rotations and is considered necessary to be accepted by the team. Discrimination was also reported by several junior doctors, with most incidents being in the form of microaggression and cultural insensitivity.

I'm a surgically inclined junior doctor and bullying is part of the culture in surgery. It’s like a boys boarding school where the guy gets bullied on the first day. You have to join the pack. You have to go through that phase. It’s a kind of test [D9, male].

Almost every consultant has asked me “Like I know you're Canadian, but what are you really?” [D15, female].

While the culture among junior doctors themselves is generally good, the overall team culture depends on the senior staff and what they prioritise.

I don't do that (taking breaks) much myself, because other people in the team don't do it, and then it’s very weird if you go do it [D6, female].

There is ongoing stigma regarding mental health among doctors, with the perception that a struggling doctor is a weak doctor. There is also a lack of open discussion with colleagues at work about mental health as a result. Junior doctors are often intimidated by senior staff and feel unsupported, leading to reluctance to ask for help.

Doctors don't like to be seen as weak or incompetent in managing their own issues, so they don't display them at all. They don't disclose it to other parties … it keeps growing in the background and eventually if they don't have a good outlet, the issue will burst, and they will run into trouble [D9, male].

While there is confidential counselling available to junior doctors and many participants reported that they believe it would be beneficial, there was a lack of perceived confidentiality, a fear of using such services impacting future job prospects, and a preference for external psychologists who are less likely to know or work with the junior doctors than internal psychologists.

They say it’s [free counselling services offered to junior doctors] completely confidential, but some nurses that I work with have said … “don't ever go to that service because you don't know if it’s actually confidential.” And then you're worried if you’re struggling with something, is your employer going to find out? … There’s a lot of fear around using that service that I’ve overheard other people talking about [D15, female].

Beyond the workplace, barriers to well-being strategies included barriers to exercise, such as tiredness, having to travel to the gym or sporting venue, a lack of time and lack of accountability at the gym when compared with a team sport. A lack of facilities at the workplace to encourage active forms of transport to work such as cycling is also a barrier.

I would also feel bad if I didn’t show up (to soccer). You’re signing yourself up and forcing yourself to commit to something that is going to help you and also that you enjoy [D13, male].

Actually having to go to the gym is a barrier in itself. Even though I live a two-minute walk from the gym, you just can't be bothered sometimes. Being tired from a big day is a barrier [D13, male].

Barriers to eating a healthy, balanced diet included unhealthy options available at work, a lack of time to prepare healthy meals at home and inconsistent eating times.

I try to consciously think about what type of food that I'm eating. I try and avoid all the high sugar high fat stuff that’s available around the workplace spaces [B1, male].

Theme 3: future interventions suggested by junior doctors to support well-being

While some junior doctors have well-being strategies in place, there continues to be room for improvement to maintain and improve the well-being of junior doctors in the future.

Junior doctors suggested the ability for junior doctors to control their work scheduling to a degree can be effective as it allows them to take time off as required in order to practice well-being strategies and safeguard their mental health.

I think it would be useful to have a regular half day off … I think it’s useful to have some time off even during the week, so you can go to appointments and things that don’t open on the weekend [D10, male].

Another intervention suggested was financial subsidies to encourage junior doctors to undertake self-care activities, such as gym memberships. Furthermore, facilities such as bike lockers and showers were suggested as interventions that could enable junior doctors to be more physically active and use active forms of transport to work.

With gym memberships, if there’s financial incentive, like if it’s cheaper to obtain, then people will be more likely to do it [D10, male]

For people who cycle into work, having a shower and changing rooms and somewhere to lock up your bike would be helpful. [D1, male]

Events and workshops organised within the hospital or community events were suggested by junior doctors to encourage participation from different members of the hospital. Additionally, providing complimentary food to junior doctors could also encourage them to engage in such events. Lastly, junior doctors reported that allocated time for junior doctors to discuss their mental well-being could be a useful workplace intervention.

We have social events for just the junior doctors, but I think having social events so you can meet the nurses and the physios and other staff on a personal level would really help build their professional relationship so that you could work with them more easily because [D8, female].

15 minutes of time at the end of our intern education sessions which is protected to be able to actually just have a chat with some of your friends about what’s been going on, how they are doing etc. … just 15 minutes where it’s completely protected time in the room just amongst your peers, no administrators there, it’s just some time to take for yourself to take a breath and share experiences with your colleagues [B1, male].

There are also other interventions that can be implemented within medical schools to ease the transition from medicine into the internship year for junior doctors. This includes a clear description of the expectations of an intern so that they are not caught off guard when they start working in hospitals, and a transition placement in the final year of medical school.

I think as an intern, often you're a glorified administration assistant, and you don't really train to do that in medical school. A lot of the things that you do … you sort of have to learn on the job and they're very department and ward specific … there’s lots of different processes that you need to learn quickly [D12, male].