East Asian Arch Psychiatry 2024;34:128-33 | https://doi.org/10.12809/eaap2447

ORIGINAL ARTICLE

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Nur Rasyidah Binti Mohd Sabri, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia
Azlina Wati Binti Nikmat, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia
Salina Binti Mohamed, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia
Norni Binti Abdullah, Department of Psychiatry and Mental Health, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

Address for correspondence: Dr Azlina Wati Binti Nikmat, Department of Psychiatry and Mental Health, Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh Campus, Selangor, Malaysia. Email: azlinawati@uitm.edu.my

Submitted: 5 September 2024; Accepted: 20 November 2024

In Malaysia, house officers are required to undergo mandatory supervised clinical training before registration as practising doctors. There are six compulsory postings, and each rotation lasts for at least 4 months. House officers often present with psychological distress (such as anxiety), which affects functioning, quality of life, commitment, and performance. The prevalence of anxiety among house officers in Malaysia has been reported as 33.7%¹; factors associated with anxiety are mainly work-related stressors such as performance pressure, poor relationships with colleagues or superiors, lack of career pathway, frustration with hospital bureaucracy, poor work-life balance, and avoidance-based coping strategies.^2-5

Psychological flexibility is the capacity to accept, adapt, and change in response to changing internal and external stimuli, whereas psychological inflexibility is the incapacity to do so.^6-8 Psychological flexibility is a mediator in the manifestation of psychological distress such as anxiety. Thus, a high level of psychological inflexibility is associated with an increased risk of anxiety and poor overall psychological health. Psychological inflexibility can worsen stress and lead to the development of depression and anxiety.⁶ A population-based study in Sweden showed that psychological inflexibility was positively correlated with anxiety symptoms.⁹ Similarly, psychological inflexibility is a mediator of the negative impact on anxiety among senior undergraduate and graduate students of healthcare careers (medicine, nursing, and clinical psychology).¹⁰ This study aimed to determine the associations between anxiety and sociodemographic factors, work-related variables, and psychological inflexibility, and to identify predictors for anxiety among house officers in a hospital in Malaysia.

Methods

This cross-sectional study was conducted at Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia, which is the second-busiest hospital for inpatient admissions and the busiest for outpatient services in Malaysia.¹¹ House officers aged ≥18 years were recruited from seven departments (general surgery, obstetrics and gynaecology, paediatrics, orthopaedics, emergency, anaesthesiology, and psychiatry) between December 2023 and March 2024. House officers who were involved in primary care postings at nearby healthcare clinics were excluded, as were those from the medical department (because the head of the department did not grant permission).

Based on a study in Malaysia that reported the prevalence of anxiety among house officers as 33.7%,¹ the estimated number of participants needed was 135, assuming a 5% margin of error and a 20% attrition rate. Convenience sampling was used.

House officers were approached during continuous medical education sessions. Those who consented to participate were given a QR code to access a questionnaire. Data recorded included sociodemographic profiles and environmental/work-related variables. Participants were asked to rate their levels of psychological flexibility and anxiety, as well as their perceived factors for anxiety (based on previous study findings^2-4).

Psychological flexibility was assessed using the seven- item Acceptance and Action Questionnaire-II (AAQ-II).¹² Each item is rated on a seven-point Likert scale from ‘never true’ to ‘always true’. Total scores range from 7 to 49; higher scores indicate less psychological flexibility. The Malay version of the AAQ-II has a Cronbach’s alpha of 0.93 among non-clinical samples, with good reliability and validity,¹³ comparable with the 0.84 for the original AAQ-II.¹⁴ The cut-off scores of 24 to 28 are associated with depression and anxiety.¹⁵

Presence of anxiety over the previous 2 weeks was assessed using the seven-item Generalised Anxiety Disorder (GAD-7) scale. Each item is rated on a four-point Likert scale from ‘not at all’ to ‘nearly every day’. Total scores range from 0 to 21; higher scores indicate more severe anxiety. A cut-off score of 8 has 92% sensitivity and 76% specificity in identifying clinically relevant anxiety.¹⁶

Statistical analyses were performed using SPSS (Windows version 29.0; IBM Corp, Armonk [NY], United States). A p value of <0.05 was considered statistically significant. Data distributions were tested for normality. Non-parametric distributed data were presented as median (interquartile range). Participants with and without anxiety were compared using the independent t test for continuous variables or the Chi-squared test or Fisher’s exact test for categorical variables. Simple logistic regression analysis was conducted to determine whether any significant variables were associated with anxiety. Multiple logistic regression analysis was performed to determine predictors for anxiety.

Results

In total, 43 male and 95 female participants (mean age, 27.5 years) were included in the analysis (Table 1). Of the 138 participants, 75 (54.3%) were classified as having anxiety based on their GAD-7 scores. The anxiety and non-anxiety groups were comparable in terms of baseline characteristics, except for marital status (p=0.023). Participants with anxiety were more likely to have a psychiatric condition (10.7% vs 1.6%, p=0.031), work more hours per week (73.95 vs 67.84, p=0.017), and have higher AAQ-II scores (31.61 vs 19.63, p<0.001).

Common factors that the house officers perceived to be associated with anxiety included poor work-life balance (85.5%), hospital bureaucracy (77.5%), and performance pressure (73.9%) [Table 2]. Predictors for anxiety were the AAQ-II score (adjusted odds ratio=1.19, p<0.001) and working hours per week (adjusted odds ratio=1.04, p=0.034), after adjustment for sex, marital status, and psychiatric condition (Table 3).

Discussion

The prevalence of anxiety among house officers in our hospital was 54.3%, which is higher than the 33.7% among house officers in Malaysia during the COVID-19 pandemic and the 39.9% before the pandemic.⁵ However, it was consistent with other studies for house officers in teaching hospitals, with the prevalence ranging from 50% to 60%.^2,19 The prevalence of anxiety among the general population in Selangor, Malaysia was only 8.2%.²⁰

Although marital status differed significantly between participants with and without anxiety, marital status is not correlated with anxiety among Malaysian house officers,² consistent with other studies involving healthcare workers. However, marriage does appear to be a protective factor against psychological distress,²¹ whereas being single can predispose people to anxiety.²² This can be explained by the positive effect of social support in marriages.²³ Nevertheless, marital status is context-dependent and influenced by cultural and societal norms, with varying exposure to stressors and mental health risks being associated with different marital statuses.²⁴

Anxiety is a common comorbidity in mental health conditions. However, the present study showed no significant associations between anxiety and medical history, substance use, smoking, or alcohol consumption.

The working hours among house officers were approximately 71 hours per week, consistent with the Malaysian Graduate Medical Officer Flexi Timetable system, which stipulates that house officers should work 65 to 75 hours per week.²⁵ Each department has flexibility as long as it adheres to the initial framework. Notably, participants with anxiety had significantly longer working hours per week, consistent with a study of junior doctors in Australia that found associations between poor mental health outcomes and working ≥50 hours per week.²⁶ Long working hours are also factor in mental health issues among the general population.²⁷

Seniority in housemanship is not associated with anxiety.^2,28 However, a study in West Malaysia reported that working experience was a protective factor for anxiety among house officers, probably owing to the increased coping experience with the tasks and duties.³

Most house officers reported that poor work-life balance was the primary cause of anxiety, followed by hospital bureaucracy and performance pressure. Work-life balance is the leading cause of stress.⁴ Anxiety is associated with imbalances between work effort, job demands, and home-related stress,²⁹ which are components of work-life balance. Additionally, relationships with colleagues and superiors were also a common cause of anxiety, consistent with findings from a similar population.³⁰

The mean score for psychological flexibility among house officers was 26.14, which was higher than that in other studies involving medical students and early- career professionals.^10,30 Participants with anxiety had less psychological flexibility and longer working hours per week, consistent with findings of other studies.^31-36 Psychological inflexibility is associated with poor mental health outcomes.³⁷ High job demands and the need for rapid decision making can exacerbate feelings of anxiety when coupled with an inflexible capacity to adapt, accept, and change accordingly. Work-related stressors can affect the mental health of junior doctors; extended shifts and the pressure of life-or-death decisions can affect the wellbeing of practitioners.

Despite multiple interventions aimed at reducing working hours, stakeholders should ensure effective implementation of these interventions. There is still a gap in enhancing support systems that foster adaptive coping mechanisms and psychological resilience among house officers. Our findings suggest incorporating an acceptance and commitment therapy–based programme into housemanship to cultivate a flexible attitude toward challenging psychological events. Additionally, the AAQ-II can serve as a screening tool to identify individuals with high psychological inflexibility, allowing for early intervention.

There is a need to reassess work schedules to balance professional demands and wellbeing. Efforts have been made to enhance working conditions for junior doctors. For example, the European Working Time Directive limits doctors to a maximum of 48 working hours per week. However, any adjustments to working hours must not compromise the training to acquire sufficient knowledge. The challenge lies in determining the optimal balance. Longitudinal studies could shed light on the long-term impact of working hours on anxiety among house officers, potentially guiding policy changes in the healthcare sector.

The present study has several limitations. Convenience sampling was used, and thus participants were not randomly chosen; the sample may therefore not be representative of the population being studied. The use of self-report questionnaires is subject to recall bias and reporting bias. The cross-sectional design can identify associations only, not causal relationships. Data were collected from a single hospital and thus the generalisability of our findings may be limited, although Hospital Tengku Ampuan Rahimah is one of the busiest hospitals in Malaysia. Other factors associated with mental wellbeing such as sleep and fatigue,³⁸ burnout,³⁹ coping styles,^5,40 and personality traits that may be confounders were not assessed. Given these limitations, the results should be interpreted with caution. Future research should aim at understanding the role of psychological inflexibility in anxiety among house officers.

Conclusion

Psychological inflexibility and excessive working hours are predictors for anxiety among house officers in a hospital in Malaysia. Institutional changes and individual-level interventions could lead to a healthier, more effective workforce.

Contributors

All authors designed the study, acquired the data, analysed the data, drafted the manuscript, and critically revised the manuscript for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

Conflicts of interest

All authors have disclosed no conflicts of interest.

Funding / support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data generated or analysed during the present study are available from the corresponding author on reasonable request.

Ethics approval

This study was approved by the Faculty Ethics Review Committee, Faculty of Medicine, Universiti Teknologi MARA (reference: 100 - FPR (PT.9/19) (FERC-02-23-02)) and registered under the National Medical Research Register (reference: 23-00833-ROY). The participants were treated in accordance with the tenets of the Declaration of Helsinki. The participants provided written informed consent for all treatments and procedures and for publication.

Acknowledgement

The authors thank the director and heads of departments and the Clinical Research Unit at Hospital Tengku Ampuan Rahimah, Klang, Selangor for their valuable cooperation.

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