There are several main findings in this longitudinal study. First, whilst junior-year residents had no significant changes in perception of learning environment and coping strategies, there was an increase in the level of perceived stress at timepoint 4 as compared with baseline. Second, for senior-year residents, a decrease in perceived stress level was observed at timepoints 3 and 4 compared with baseline. This was accompanied by better perception of their learning environment (overall, role autonomy, social support, teaching) and adoption of problem-focussed coping over time. Overall perception of learning environment and perceived stress scores were negatively correlated regardless of seniority. Different coping strategies were correlated with overall perception of learning environment when junior and senior resident groups were examined separately.
For junior-year residents, the perception of their learning environment and coping methods did not appear to change over the timepoints. Additionally, they experienced higher stress levels at timepoint 4 as compared with baseline. These findings can be understood from situativity theory [23
] and an understanding of community of practice [29
]. New learners (junior-year residents) join a community of practice initially from the edge and learn through a process of legitimate peripheral participation [37
]. Situated learning encompasses not only the acquisition of knowledge and concepts, but also all that is inherent within the learning environment, including the social interactions [23
] which are measured by PHEEM, and thus may not seem to change much early on in training. Furthermore, junior-year residents may have fewer opportunities to make independent clinical decisions as they are part of an inter-professional team with more experienced colleagues, contributing to a perception of reduced autonomy. Concomitantly, coping strategies can moderate levels of stress experienced during training, and the lack of coping strategy modification (positive and negative) found in junior-year residents over time could have contributed to greater perceived stress at timepoint 4. Poorly managed stress may subsequently influence their perception of the learning environment [38
On the other hand, perceptions of their learning environment for senior-year residents improved over time. Additionally, they experienced lower stress levels, and had increased use of problem-focused coping. These observations could be explained by their progress into full participation within communities of practice [29
] and involvement in the process of collaborative elaboration [27
]. Senior-year residents are more likely to have had opportunities to establish working relationships with fellow residents during various clinical rotations. These shared experiences provide a basis for them to reflect on their own perspectives in a community setting, which generates knowledge that can be shared amongst learners [27
]. This enhances both personal and professional development [29
] and could contribute to the perception of a learning environment that is supportive and intellectually stimulating. Senior-year residents were also noted to have significantly increased their use of problem-focused coping strategy later in their training. This could indicate attempts at adjusting coping strategies which possibly attenuated the effect of accumulated stress throughout residency. Lower stress levels in turn contributed to more positive perceptions of their learning environment [38
Correlations among learning environment, stress levels, and coping strategies
Stress levels were significantly correlated to various domains of perception of learning environment for both groups of residents in junior and senior years of training across multiple timepoints, reinforcing findings by Llera and Durante [38
]. This underscores the need to take into consideration the bidirectional influence between learning environment and stress. Educators should consider the domains of role autonomy, social support, and teaching as critical avenues of early intervention for residents.
Different coping styles were associated with better perception of learning environment in junior and senior residents, with less active-avoidant coping for junior-year residents and less religious/denial coping for senior-year residents reaching significance. Coupled with the finding that coping styles of junior-year residents did not change significantly over time, poor perceptions of learning environment could be resistant to change in junior-year residents who prefer active-avoidant coping. As various learning outcomes [6
] and the well-being of residents [9
] could be negatively affected by poor perceptions of their learning environment, educators may consider prioritizing the promotion of functional coping strategies in residents.
Ways to help residents in junior and senior years of training
How then can junior and senior psychiatry residents be further assisted in their learning journey? The basic tenets of situativity theory [23
] and community of practice [29
] are that learning takes place within a context and through social interactions respectively. For junior-year residents, the frame of interconnecting components of learning (identity, meaning, practice, community) within a community of practice can be considered [29
]. These four components are associated with ideas about learning as becoming, experience, doing and belonging respectively. First, for learning as becoming, socialization of these residents into the specialty is useful for creating a supportive learning environment. This can be done by pairing them with senior buddies who can encourage the development of positive coping strategies and give advice about professional training, which can aid the development of professional identity. An undergraduate study involving first-year medical students has also shown that one main contributor to perceived stress is difficulty in establishing contact with other medical students [39
]. Second, for learning as experience, closer supervision especially at the incipient stage of training can be crucial in guiding professional development. Third, for learning as doing, active involvement of junior-year residents in clinical decisions and case management within inter-professional teams can also move them from legitimate peripheral participation [37
] to full participation over time, enhancing perceived role autonomy. Fourth, for learning as belonging, inclusion of residents in junior years within professional activities such as continuing medical education sessions and non-academic activities can foster a greater sense of being part of the specialty to which they have committed their time and effort.
Pertaining to senior-year residents, three essential constituents of a community of practice [29
], namely mutual engagement, joint enterprise and shared repertoire, can be a useful frame to further aid their learning within the learning environment [40
]. Mutual engagement refers to interaction and participation in work and non-work related activities [40
]. In this regard, senior-year residents can be involved as both a mentor, through the aforementioned buddy system, and a mentee, by being assigned a mentor for personal guidance. This increases opportunities for exchange of ideas and reflective learning with colleagues of varying levels of experience during training. Joint enterprise refers to the need for the group to respond to an internally created mandate rather than an external one [40
]. A sense of role autonomy and positive perception of the learning environment [30
] can be fostered by allowing senior-year residents to take charge of some portion of their training (e.g. curriculum planning together with faculty). Shared repertoire refers to the routines, tools, and ways of doing things that the community has adopted [40
]. In this context, senior-year residents can be incrementally involved in training juniors, which can help develop a shared purpose and processes in clinical practice. The PHEEM rating scale [30
], which captures domains of perceptions of role autonomy, teaching and social support, can potentially be administered over time to ascertain the changes within the learners at different levels of seniority in the perception of their learning environment following the implementation of these suggested measures.
There are several limitations of the study. First, despite being a National Psychiatry Residency Program, the overall intake per year is still small compared with other similar Psychiatry Residency Programs internationally. Second, despite our best efforts, there is greater attrition at the last timepoint of follow-up. Third, inclusion of other factors such as personality variables and contemporaneous life events within reasonable test burden could have proffered further insights into other contributors towards the resident’s perceived learning environment.
In conclusion, we found differences between junior and senior psychiatry residents in that the latter had better perceptions of their learning environment over time related to role autonomy, teaching and social support with a corresponding reduced level of perceived stress and increased employment of problem-focused coping. This is consistent with theories of learning emphasizing the importance of context, participation, and social interaction within a community of practice to facilitate learning. Based on these findings and associated theories of learning, we have suggested several ways to further enhance learning for these psychiatry residents within a National Residency Program, which are applicable to other similar training programs.