The Psychological Well-Being of ‘Houseman’ Medical Officers in Malaysia

Housemanship’ is one of the most challenging phases for a person who wants to become a doctor and wants to choose medicine as his or her career. This paper aims to discuss the psychological well-being issues that are often faced by ‘houseman’ medical officers throughout their undergoing housemanship. Literatures search was conducted based on previous studies related on well-being and psychological well-being issues faced by ‘houseman’ medical officers. This initial literature reviews’ study confirmed that many ‘houseman’ doctors experienced considerable stress, anxiety, depression and burnout. The source of stress was multi-faceted, but workload wass the most significant stressor. Having good coping strategies help them to overcome their problem and might relief stress and could foster good psychological well-being during their training duration.


Introduction
A 'houseman' medical officer is a trainee doctor who has just graduated from any medical schools and is in a period of observation and evaluation before he or she can be discharged to serve and be fully responsible for all decisions made against the patients. 'Housemanship' is a process for them to translate anything learned during medical school into practical form. This is the time for them to apply what they have learned to real world.
In simple words, 'housemanship' is a transitional phase of a medical graduate before being fully licensed and confirmed as a medical practitioner. Malaysian Medical Act 1971 defines 'Housemanship' as the period of training in resident medical practice for the purpose of being fully registered medical practitioner. This mandatory training is to produce healthcare professional and patient-oriented doctors for the betterment of our public health services (Tan et al., 2013).
Early 'housemanship' is a crucial time in career development of 'houseman' medical officers. In the early few months of 'houseman' medical officers, they may have new role of responsibilities and expectations. In fact, early 'housemanships' are wrestling times with the role transition, from dependent to autonomous, from accountable to responsible, from learner to teacher, from supporter to leader (Ackerman et al., 2009). At this point, 'houseman' medical officers will find memorable scene that could provide them with insight into their developing professional identities.
However, during 24 months of 'housemanship', the junior medical officers will frequently encounter intense experiences that may affect their quality of life and well being. The purpose of this study was to explore the factors related to 'houseman' officers' psychological wellbeing during 'housemanships'.

Psychological Well-Being
According to World Hapiness Report 2015, Malaysia was ranked 61 st out of 158 countries audited for its' population happiness rate (Helliwell, Layard & Sachs, 2015). These findings indirectly indicate that the level of psychological well-being of Malaysians is not at a positive level. The elements of psychological well-being are diverse, yet what is important is that they lead to happiness either internally or externally. Hence, many researchers see these aspects in varying conditions. This situation proves that sensitivity in psychological well-being by an individual depends on how they control themselves wisely. This is in line with the concept of psychological well-being stated by Bradburn, happiness and serenity is the result of psychological well-being and is the goal the highest that every human being wants to achieve. From the Islamic perspective, psychological well-being refers to the spiritual aspects that reflect the human heart, soul, mental and psychology (Hassan, 2000). Whilst, Ryan and Deci (2001), defines psychological well-being as an experience and optimal psychological functioning of an individual. It is not just an interpersonal relationship but more towards intense scientific. In line of that, The World Health Organisation (2003) referring psychological well-being as individuals who are healthy and mentally prosperous who are able to maintain harmonious relationships with others, participate in community activities and can thrive in society.
Psychological well-being is directly proportional to the quality of life of an individual. Quality of life (QOL) as an individual's perception of their position in life, in the context of culture and value system in which they live and their relationship to the responsibility, expectations, standard and concerns (World Health Organisation, 2010). WHO has outlined four key elements that affect quality of life. These elements are psychological, physical health, social relationships and environment.
Thus, psychological well-being can be concluded as a person's psychological state formed from life experiences his daily being subjectively assessed as well as the extent to which it is evaluate his ability to subjectively express himself. Ryff and Keyes (1995) claims that psychological well-being consists of six dimensions namely self-acceptance, positive relationships with others (positive relations), autonomy, environmental mastery, purpose in life and personal growth. For autonomy, the measurement revolves around the evaluation of strong personal standards, independent of others and ready for all the challenges in life. The second dimension, on the other hand, is the mastery of the environment like having more towards control good environment and make things affectively follows its' suitability. Dimensions for positive relationships with others refer to liking, empathy, and understand the relationship in a good element. Whilst, dimensions of self-development involving feelings who is constantly evolving and ready to find something latest in life. The dimension of goals in life refers to having fully defined life objectives. Finally is the dimension of self-acceptance which carries the meaning of positive behaviors and attitudes in life. Descriptions related to the elements of psychological well-being by Ryff are as follows in Table 1:

PWB Variable Definition
Environmental Mastery Feelings of competence and capacity to manage and meet the responsibilities of everyday life / one's ability to choose or create an environment which corresponds to the psychological state of the self in context self development

Purpose in Life
Feelings of purpose and having a sense of life direction and that past and present experiences are meaningful / clarity of life purpose is an important part of mental health features on someone

Autonomy
The extent to which one views oneself as selfdetermining and independent, resisting pressure to meet social expectations / ability to determine for yourself the ability to regulate behavior and freedom

Positive Relations with Others
The sense that one has warm, satisfying, and trusting relationships and are socially concerned/ one's ability to build relationships who are familiar with others

Self-Acceptance
The capacity for accepting and acknowledging one's strengths and virtues as well as recognizing one's weaknesses / positive assessment of one's condition

Personal Growth
Capacity for continued development, potential, and openness to experience / Acquisition of personal characteristics from previous experience and continues to grow.

Psychological Well-Being of 'Houseman' Medical Officers in Malaysia
Happiness at work is very important for individuals because if they happy in the workplace have a positive perception that makes individuals satisfied, productive, and low turnover make a total amount of quality manpower (Ningsih, 2013). In recent years, there has been an increasing interest research regarding psychological well-being issues among employees (Yunus & Mahajar, 2011), students (Trpcevska, 2017;Rozubi, 2017;Alim et al., 2016;Omar, 2009;Nordin & Talib, 2009), parents (Desa et al., 2015;Hassan, 2014;Hassan 2013), old citizens (Mudayat, 2014), patients (Bahari, 2016), and professionals (Cvejic et al., 2017;Mahani, Shahrir & Melati, 2017;Nor, 2011;Ratanasiripong & Wang, 2011;Agur & Tenıas-Burillo, 2004).  Previous research by Nogueira et al. (1997) have disscused outlined based on psysholgical and psychiatric morbidity among residents. In these study reported depression and sleep deprivation appear to be two of the most significant psychological problems that affect residents and are considered to be the main symptomatic reactions to this period. A number of researchers also have reported sleep deprivation among house officers is of growing concern. In developing countries, junior physicians are highly susceptible to develop sleep impairment due to long working hours, on-call duties and shift work schedule (Surani et al., 2015;Baldwin, Daugherty & Yaghmour, 2011;Cramer et al., 2016;Deary & Tait, 1987;Fargen, Larrew & Turner, 2019;Wali et al., 2013;Weiss, Kryger & Knauert, 2016).
The issue of 'houseman' medical officers has received considerable critical attention from many researchers. A considerable amount of literature has been published on burnout and stress among 'houseman' medical officers. Studies about stress and burnout among 'houseman' junior doctors were done locally and abroad (Samsudin, Isahak & Rampal, 2018;Wu et al., 2018;O.Imo, 2017;Stawicki, 2017;Tallentire et al., 2017;Chin et al., 2016;Soares & Chan, 2016;Crock & Crock, 2015;Kim Lee & Choi, 2015;Mata et al., 2015;Vivekanandan et al., 2016;Zuraida & Zainal, 2015;Eley et al., 2013). Their studies shown that burnout may precede chronic stress and depression, in which case, burnout inventions could serve as protective treatment for chronic stress and depression in house officers. Thus, increases in stress will predict a decrease in job satisfaction.
In Malaysia, there have been researchers who study issues of psychological well-being among 'houseman' medical officers since the 1970's. Those issues include stress, anxiety, depression, and burnout. A list of studies in Malaysia can be found in Table 3.

Table 3: The studies about 'houseman' medical officers in Malaysia
The authors describe stress and burnout response syndrome among 'houseman' medical officers in training. The findings of the study indicate that housemanship, family relation and lack of courage severely affected house officers, however, may also suffer from major depression, suicidal ideation, and substance abuse. Possible contributing stresses include sleep deprivation, excessive work load, patient care responsibility, perpetually changing work conditions, and competition (Small, 1981). A primary concern of 'houseman' medical officers is they feel undervalued due to poor team working and relationships, bullying, workload, resources, and lack of positive feedback. And what makes 'houseman' medical officers feel no autonomy is lack of appropriate responsibility for clinical decision making, clinical complexit, overburdening and too much senior input, and reducing autonomy to make decision (Singh et al., 2019).
Recent evidence suggests that suggest the need for interventions to provide positive coping skills in handling the specific stressors. Finally, to improve psychological well-being among 'houseman' medical officers, six dimensions namely self-acceptance, positive relationships with others (positive relations), autonomy, environmental mastery, purpose in life and personal growth of psychological well-being should be taken seriously and given due attention by 'houseman' medical officers.

Methodology
This research will be conducted using the mixed method design, whereby both quantitative and qualitative approaches will be combined. It is going to be an explanatory mixed method research conducted in two sequential phases. In the first phase, the study will deploy a survey questionnaire which will gather data on psychological well-being among sampled 'houseman'

Authors Issues
Ismail medical officers. It is then followed by the second phase in which the in-depth interview wil be conducted using a semi-structured protocol in order to collect information to further explain vital data from the first phase. The stratified random and purposive sampling procedures will be employed to sample research participants in both phases, while Statistical Package for Social Sciences (SPSS) version 23.0 and NViVo version 10 will be used as data analysis tools for both quantitative and qualitative phases.

Conclusion
The experiences of internship provide many potential triggers for personal growth. The balance between facilitators and barriers helps to determine whether personal growth is more or less likely to occur. Experience and responsibilities throughout housemanship should mature them and others should engage with them to identify improvements to improve their well-being and working lives. 'Houseman' medical officers should know their limitations and when and how to seek support. This can be sought from healthcare professionals other than doctors, where relevant.