Well-being and Burnout in Psychologists

Well-being and Burnout in Psychologists 1

Abstract

Objective: Burnout among healthcare professionals is an increasing concern

due to adverse outcomes for clinicians, clients, and organisations (Bridgeman

et al., 2018; Azoulay et al., 2020). One identified systematic review

(McCormack et al., 2018) has explored burnout in psychologists and

psychological therapists; however, no identified reviews have focused solely on

psychologists. This review aimed to investigate the prevalence, causes and

factors associated with burnout in psychologists.

Method: Studies related to burnout in psychologists, published before

September 2021, were obtained from multidisciplinary databases. The search

yielded 582 papers, 26 papers were eligible for review. Researchers conducted

a thematic synthesis (Nicholson et al., 2016). Final themes were developed by

identifying commonalities across the sub-themes from separately grouped

qualitative and quantitative studies.

Findings: Psychologists experienced moderate to high levels of burnout related

to emotional exhaustion. Narrative synthesis highlighted three themes

concerning burnout-related factors: age and gender, occupational experiences

such as job demands, and personal resources such as humour and beliefs

Well-being and Burnout in Psychologists 2

about burnout. The development of support networks was found to be an

important protective factor for the included psychologists.

Conclusions: Emotional Exhaustion (EE) may play a key role in psychologists'

experiences of burnout, and further research relating to the experiences of EE

in younger and recently qualified psychologists may help to inform prevention

and intervention strategies.

Keywords: psychologists, burnout, emotional exhaustion, systematic review.

Introduction

Like many healthcare practitioners, psychologists may experience

burnout during their careers (Turnbull & Rhodes, 2021). The increasing concern

regarding burnout in healthcare populations is rooted in adverse personal and

occupational outcomes (Bridgeman et al., 2018). Burnout can lead to poor

mental health in healthcare workers (Morse et al., 2012); however, its impact is

not limited to the individual. Poor patient outcomes (Hall et al., 2016) and

interpersonal difficulties with colleagues (Guidroz et al., 2012; Vincent et al.,

2019) have also been associated with burnout. Burnout significantly contributes

to the absenteeism, retention, and recruitment costs healthcare providers face

(Kirby., 2023).

Psychologists comprise the most significant proportion of the NHS

psychological professions workforce at over 40% (HEE., 2021). The Mental

Health Implementation Plan proposed ambitious plans to recruit 2,520

additional psychologists into the workforce by 2024 (HEE., 2021) to meet the

demand for psychological interventions in the NHS (Iqbal et al., 2021). Despite

this, burnout in UK-based psychologists is under-researched. Understanding

Well-being and Burnout in Psychologists 3

psychologists' burnout experiences is imperative to supporting psychologists,

teams, clients and the ongoing expansion of the psychological workforce.

This review synthesised international literature relating to burnout in

psychologists. The conceptualisation and measurement of burnout are briefly

explored alongside research concerning burnout among psychologists.

Well-being and Burnout in Psychologists 4

Burnout

Burnout was introduced in 1975 as a work-related stress condition in

healthcare volunteers, resulting from long-term exposure to work-related stress

(Freudenberger, 1975). Maslach and colleagues later described burnout as a

state precipitated by a prolonged period of chronic emotional and interpersonal

workplace stressors (Maslach et al., 2001). Burnout is characterised by three

dimensions; exhaustion, cynicism, and inefficiency (Maslach et al., 2001).

Exhaustion represents the depletion of emotional and physical resources.

Cynicism, or depersonalisation, reflects the individual's negative or critical

responses towards their job, clients and colleagues, whilst reduced efficiency

refers to feelings of incompetence or lack of personal achievement.

Maslach's (1982) model of burnout led to the development of the

Maslach Burnout Inventory (MBI; Maslach et al., 1997), a 22-item self-report

tool designed to measure the presence of the three dimensions of burnout. The

MBI is well-validated and has been adapted to several other languages and

populations (Pisanti et al., 2013; Dolan et al., 2015). Despite being considered

the gold standard in burnout measurement (Williamson et al., 2018), the MBI is

not the only measure used in research. The MBI is based on Maslach’s three

dimensions; however, other proposed dimensions can be used to measure

prevalence. The Copenhagen Burnout Inventory (CBI) (Kristensen et al., 2005),

for example, identifies the presence of burnout by using three different

dimensions of burnout: personal, work-related, and client-related. Edú-Valsania

and colleagues (2022) provide a comprehensive review of burnout

measurement that is out of the scope of this review. It is, however, essential to

acknowledge that researchers' choice of burnout tools is crucial. It significantly

Well-being and Burnout in Psychologists 5

impacts how burnout is conceptualised, the aspects of experience being

measured, and the potential interpretation and impact on proposed

interventions.

Burnout in Psychologists

Psychologists are at a high risk of work-related emotional distress and

burnout (Kumary & Baker, 2008; Emery et al., 2009; Di Benedetto & Swadling,

2014). This is partly due to the intensity of the emotional experiences that

constitute their daily working life, including witnessing distress, trauma, and loss

(Rabu et al., 2016; Wise & Barnett., 2016). High caseloads, long waiting lists,

and high levels of autonomy have all been identified as additional work-related

stressors for psychologists (Johnson et al., 2012; McCormack et al., 2018).

Though these differ cross-culturally, long wait times (Kowalewski et al., 2011;

Olver et al., 2011; Ofonedu, et al.,2017; Punton et al., 2022), difficulties with

recruitment and retention (Fukui, & Salyers., 2019; Cosgrave., 2020), and

increasing demand are challenges faced by psychologists internationally. The

accumulation of these challenges can contribute to the experience of burnout.

Burnout is associated with significant adverse outcomes. Evidence

suggests that burnout can negatively impact quality of life and is positively

correlated with anxiety and depression (Morse et al., 2012), suicidal ideation

(Dyrbye et al., 2008), and emotion dysregulation (Gorgievski & Hobfoll, 2008;

Toh et al., 2012). Burnout poses a severe threat to healthcare providers as

burnout can 'transfer' between colleagues (Westman & Bakker., 2008 pp 1),

leading to poorer outcomes for patients (Hall et al., 2016) and increased levels

Well-being and Burnout in Psychologists 6

of clinical errors (Wilkinson et al., 2017). At an organisational level, burnout is

associated with increased absenteeism (Johnson et al., 2018), occupational

disengagement (Millar., 2018) and job withdrawal (Sheather & Slatter., 2021).

Lastly, the increased levels of staff sickness related to burnout (Summers et al.,

2021) and the subsequent impact on the retention and recruitment of staff

contribute to the growing financial crisis related to the retention and recruitment

of NHS staff, such as psychologists (Kirby., 2023).

Not only are psychologists expected to manage the pressures and

demands described, but unlike many other healthcare professions, they are

also expected to provide interventions to support the well-being of their teams

and reduce burnout (Heneghan et al., 2014; BPS., 2017). In addition,

psychologists hold leadership and management responsibilities alongside their

clinical workload (Channer et al., 2018). Though this varies, this is often not the

case for the healthcare workers with whom psychologists are grouped within

the research, e.g., mental health practitioners. There is also evidence that

psychologists may experience mental health stigma related to a perceived

expectation to know how to cope, which could negatively impact supportseeking

(Tay et al., 2018). The research does not provide insight into the specific

impacts of these factors concerning burnout; however, it is reasonable to

suggest that these additional demands mean that psychologists' experience of

burnout may differ somewhat from their healthcare colleagues. As such, the

experiences of psychologists must be considered independently of their

healthcare colleagues to allow researchers to identify specific experiences and

needs of the population.

Well-being and Burnout in Psychologists 7

Review Rationale

Burnout in psychologists is a complex issue that can be impactful at

individual, service, and organisational levels. To the researcher's knowledge,

only one systematic review, that of McCormack and colleagues (2018), has

explored burnout in psychologists capturing data published before 31st

December 2016. The proposed review may capture research published

between 2016 and 2022, thus providing a beneficial updated picture in relation

to the prevalence factors and causes of burnout in psychologists. An updated

review would also capture the influx in research around burnout resulting from

the impact of the Covid-19 pandemic on healthcare workers (Gonda & Tarazi.,

2022). In addition, although McCormack et al. (2018) did capture burnout in

psychologists, they also included allied mental health practitioners in their

population samples (McCormack et al., 2018). Thus the population sample is

relatively broad. By narrowing the inclusion criteria, this review can draw

conclusions specifically relating to the experience of psychologists who may

have different burnout experiences and needs compared to their

multidisciplinary colleagues. As such, recommendations can be tailored

specifically to the needs of psychologists.

To the researcher's knowledge, there do not appear to have been any

attempts to explore the research relating specifically to professional

psychologists, including data published between 2016 and 2022. For

transparency, the researcher broadened the search for existing literature

reviews to cover any published reviews exploring burnout-related concepts,

such as compassion fatigue and emotional exhaustion. Though the search did

Well-being and Burnout in Psychologists 8

yield a systematic review exploring compassion fatigue in healthcare workers

(Cavanagh et al., 2020), the population here included a broad range of

healthcare workers, with only two of the seventy-one included papers including

psychologists in their sample. A search of the Cochrane Databases yielded no

registered reviews intending to collate the proposed review question.

Review Aims and Objectives

The current paper aims to systematically review international research

regarding the causes and prevalence of burnout among psychologists.

Examining the existing research may support researchers and clinicians to

better understand the development process and potentially nuanced

experiences of psychologists. Thus, potentially leading to more appropriately

informed prevention and intervention strategies. This systematic review aims to

answer the following questions:

1. What is the prevalence of burnout among psychologists?

2. What are the causes and factors related to burnout in psychologists?

Method

Design

This paper describes a mixed-methods systematic literature review. The

Joanna Briggs Institute Clinical Appraisal Tools (JBI) (Joanna Briggs Institute,

2017) were selected to appraise the included studies' methodological rigour and

highlight potential areas of caution when interpreting the findings. A narrative,

thematic synthesis (TS) was used to analyse the identified studies to enable the

Well-being and Burnout in Psychologists 9

researchers to move beyond the original study findings and generate related

themes across the data (Thomas & Harden, 2008).

The Preferred Reporting Items for Systematic Reviews and

MetaAnalyses (PRISMA) (Page et al., 2021) guidance was used to ensure the

review was of sound quality and could be easily replicated (Appendix A).

Screening and Sampling

The SPIDER framework (Cooke et al., 2012) was adapted to

support the development of inclusion criteria and search terms.

Inclusion / Exclusion Criteria

An independent qualitative researcher and health psychologist consulted

with the researchers during the development of the inclusion criteria presented

in Table 1. Both quantitative and qualitative empirical papers were included.

Grey literature and papers not published in English were excluded. Though

peer review has not always ensured validity (Smith., 2006), grey literature was

excluded to support the review's rigour. Papers with samples of school

psychologists (SPs) were excluded to preserve the homogeneity of the sample,

as the SPs' training pathway and responsibilities differ significantly from other

registered psychologists (NASP, 2022). Papers focusing on interventions were

excluded as they fell outside the review scope.

Table 1

Inclusion and Exclusion Criteria

SPIDER Inclusion Exclusion

Well-being and Burnout in Psychologists 10

Sample Participants were trainee or qualified School Psychologists

psychologists

from one of six Pre-qualification

disciplines: clinical, health, psychologists

counselling, forensic, education or sport.

Phenomena of

Interest

One or more dimensions of burnout as

defined by the burnout tool utilised in the

study.

Design

Qualitative, Quantitative and Mixed

Methods research reporting on primary

data

Evaluation

Prevalence of burnout in the sample

Causal Factors relating to the

development or experience of burnout

Research

Type

Qualitative, Quantitative and Mixed Grey literature

Methods

Studies published in the English Existing literature, or

language. systematic reviews

Studies published in a peer-reviewed

journal. Publications not reporting

primary data

Search Terms

Search terms (STs), provided in Table 2, were developed in three stages:

1. A scoping search was carried out to generate key STs and test the

sensitivity and specificity of the search terms developed using SPIDER.

2. These were cross-referenced with the STs used in systematic reviews of

burnout in other healthcare professionals (McCormack et al., 2018;

Well-being and Burnout in Psychologists 11

O'Connor et al., 2018).

3. Consultation with the University of Exeter Psychology Liaison Librarian to

identify any database-specific medical subject headings (MeSH) terms to

improve the search strategy.

Terms relating to measurable outcomes were kept broad to reflect the

breadth of burnout dimensions. Greater sensitivity and specificity were applied

to the population terms. Search terms were applied to MEDLINE, PsychInfo,

and Webb of Science; MeSH terms and age filters were used in Medline and

PsychInfo only (Appendix B).

Table 2

Search Terms

2 Psychologist*

3 Stress*

4 Emotional exhaustion

5 Pressure

6 Coping

7 Manage

8 Well-being

9 Mental health

10 Work-related stress

11 Compassion fatigue

12 1 AND 2

13 3 OR 4 OR 5 OR 6 OR 7 OR 8 OR 9 OR 10 OR 11

14 12 AND 13

Burnout

Well-being and Burnout in Psychologists 12

Screening Procedure

Duplicate papers were identified using Rayyan Intelligent Systematic

Review software, checked manually, and then deleted. Next, titles and abstracts

were screened against the inclusion criteria, and those which did not satisfy the

requirements were rejected. As recommended by (Boland et al., 2017), the full

text of the remaining papers was then read, and papers which satisfied the

inclusion criteria were included for review. Lastly, following the National Institute

for Health and Care Excellence (NICE) (2012) guidelines for the compilation of

systematic reviews, the reference lists of all eligible papers were screened for

relevant papers not generated by the search strategy.

Data Extraction

A data extraction table was developed using the SPIDER framework,

discussions with the research team, and consideration of information pertinent

to the research questions. The table included sample characteristics, country,

study design, use of burnout measures, key findings and limitations (Appendix

C).

Quality Appraisal

Quality appraisals (QA) in mixed methods reviews can present

challenges due to the heterogeneity of the study designs (Hong et al., 2018).

The Mixed Methods Assessment Tool (MMAT) (Pluye et al., 2009a, Pace et al.,

2012, Hong et al., 2018) was developed specifically for use in mixed methods

reviews and was initially selected for this review. After completing QA on three

Well-being and Burnout in Psychologists 13

of the included papers, it became apparent that the MMAT did not capture some

of the nuances of qualitative design, such as the researcher's relationship to the

data. Additionally, the checklist format of the MMAT did not allow for descriptive

notes by the researchers, which was essential to ensure consistency of

judgement-making when reviewing a large number of studies. Alternative

options were explored, whereby papers could be assessed by tools specific to

the research design whilst maintaining some continuity of assessment quality

across the tools.

Based on this rationale, papers were assessed using analytical

crosssectional or qualitative JBI Clinical Appraisal Tools (Appendices D and E).

The JBI tools use a mix of multiple-choice and open questions to assess the

quality and allow for descriptive comments from the assessor (Joanna Briggs

Institute, 2017). Mixed-methods studies were appraised twice, once using the

appropriate quantitative checklist and then again using the qualitative checklist.

One point was awarded for each criterion fully met. Mixed methods papers were

awarded two scores. An independent researcher quality assessed six papers.

Inter-rater reliability was calculated using Cohen's kappa (k = 0.83).

Data Analysis

Thomas and Harden's (2008) thematic synthesis guidance was applied

to analyse the data and to develop descriptive and analytic themes (Figure 1).

TS was selected as it offers consistency across the analysis of qualitative and

quantitative data, is well suited to reviewing medium size data sets, and has

been successfully applied to mixed methods health-related literature reviews

Well-being and Burnout in Psychologists 14

(Dixon-Woods et al., 2005; Nicholson et al., 2016; Etkind et al., 2018; Ryan et

al., 2018). TS also encourages transparency, which is essential for the clarity

and quality of findings generated by synthesising data (Tong et al., 2012).

In line with Thomas and Harden's (2008) model, all data labelled results

or findings were extracted from the papers for analysis. The qualitative and

quantitative data from the mixed methods paper (#15) were separated and

analysed with the respective data. The analysis took place in three stages

(each stage applied to the quantitative data first and then to the qualitative

data). First, data was line-by-line coded, generating descriptive codes. Next,

codes were grouped into descriptive themes based on commonalities or

patterns in the data. Finally, to 'go beyond' the primary data (Thomas &

Harden., 2008), analytic themes were developed by critically reviewing the

descriptive themes in light of the research question. Once this process was

completed for both quantitative and qualitative papers, the analytic themes were

compared. Similarities and differences were identified, leading to an overall

account of the synthesis findings.

Well-being and Burnout in Psychologists 15

Figure 1

Summary of the data analysis process.

Quantitative Papers

Line by line coding. Codes

closely related to the

content of the data set.

Codes grouped into

descriptive themes.

Analytic themes are

developed based on the

research question

Qualitative Papers

Line by line coding. Codes

closely related to the

content of the data set.

Codes grouped into

descriptive themes.

Analytic themes are

developed based on the

research question

Overall Themes and Findings are

Generated

Analytic Themes Generated

Integrating Qualitative and

Quantitative Analytic Themes

Analytic themes are re

read.

Themes are compared,

similarities and

differences are noted

Well-being and Burnout in Psychologists 16

Findings

In total, 721 papers were identified in MEDLINE, PsychInfo and Webb of

Science searches.

Data Screening

One hundred and thirty-nine duplicate papers were identified using

Rayyan Intelligent Systematic Review software, checked manually, and then

deleted. This left 582 titles and abstracts to be screened against the inclusion

and exclusion criteria. Four hundred and eighty-nine papers were excluded at

this stage. The remaining 46 papers were read in full, and twenty-five papers

met the full criteria for inclusion. A review of the reference lists of the included

papers identified six additional papers which were screened. One additional

paper met the requirements, bringing the total number of eligible studies to 26

(full process provided in figure 2). A senior research associate at an

independent university screened six papers against the inclusion and exclusion

criteria. Inter-rater reliability was calculated using Cohen's kappa (k = 1).

Included papers are presented in Table 3, and a summary of key information in

Table 4.

Well-being and Burnout in Psychologists 17

Figure 2

Summary of the data sampling and screening procedure

PsychInfo

N= 437

Webb of Science

N= 218

Duplicates Identified and removed using Rayyan

N = 139

Title and abstracts screened against inclusion and

exclusion criteria

MEDLINE

N=66

Papers remaining

for full screening

N=46

Papers excluded

N=21

Duplicate N= 1

Participants not

psychologists N = 11

Wrong phenomenon

being studied (i.e.

stress not specifically

burnout) N = 9

Total Papers

N = 721

Papers included

for review

N=25

Additional papers

generated by

searching

references of papers

included for review

N = 1

Total Number of

papers included in

review.

N = 26

Methodologies

Quantitative Papers N = 20

Qualitative Papers N= 5

Mixed

Methods Papers N= 1

Well-being and Burnout in Psychologists 18

Table 3

Authors, publication year, titles of included papers and geographical population

in Alphabetical Order, by Author

Author and Year Title Title Geographical

of Publication Population

Ackerley et al., #1 Burnout among licensed USA and Canada

1988 psychologists

Allwood et al., #2 The relationship between Sweden

2022 personality, work, and personal

factors to burnout among clinical

psychologists: exploring gender

differences in Sweden

Berjot et al., #3 Burnout risk profiles among France

2017 French psychologists

Clarke et al., #4 The perceived effects of Australia

2021 emotional labour in psychologists

providing individual

psychotherapy

Di Benedetto #5 Burnout in Australian Australia and Swadling

psychologists: Correlations with

2014 work-setting, mindfulness and

self-care behaviours

D'souza et al., #6 The relationship between Australia

2011 perfectionism, stress and burnout

in clinical psychologists

Well-being and Burnout in Psychologists 19

Emery et al.,

2009

Associations among therapist

beliefs, personal resources and

burnout in clinical psychologists

Australia

Hammond et al.,

2018

A thematic inquiry into the burnout

experience of Australian solo-

practising clinical psychologists

Australia

Keading et al.,

2017

Professional burnout, early

maladaptive schemas, and physical

health in clinical and counselling

psychology trainees

Australia, USA,

Canada, UK

Kahill., 1986

#10

Relationship of burnout among

professional psychologists to

professional expectations and

social support.

Canada

Malinowksi.,

2013

#11

Characteristics of job burnout and

humour among psychotherapists.

USA

McCade et al.,

2021

#12

Burnout and depression in

Australian psychologists: The

moderating role of selfcompassion

Australia

McCormack et

al., 2015

#13

Practicing what we preach:

investigating the role of social

support in sport psychologists' well-

being

USA, UK, Ireland,

Australia, New Zeland

Well-being and Burnout in Psychologists 20

Rodrigeuz and

Carlotto., 2017

#14

Predictors of burnout syndrome

in psychologists

Brazil

Roncalli and

Byrne., 2016

#15

Relationships at work, burnout

and job satisfaction: A study

on Irish psychologists.

Ireland

Rupert and

Kent., 2007

#16

Gender and work setting

differences in career-sustaining

behaviours and burnout among

professional psychologists

USA

Rupert and

Morgan., 2005

#17

Work setting and burnout among

professional psychologists

USA

Rupert et al.,

2009

#18

Work-family conflict and burnout

among practising psychologists

USA

Sadusky and

Spinks., 2022

#19

Psychologists' engagement in

reflective practice and

experiences of burnout: a

correlational analysis

Australia, UK and New

Zeland

Simpson et al.,

2019

#20

Burnout amongst clinical and

counselling psychologists: The

role of early maladaptive schemas

and coping modes as

vulnerability factors

Open Globally:

Countries listed

Australia, New

Zealand, UK,

Neatherlands, USA,

Canada and 'Others'

Sim et al., 2016

#21

Thriving, burnout, and coping

strategies of early and later career

counselling centre

USA

psychologists in the United

States

Well-being and Burnout in Psychologists 21

Skorupa and

Agresti., 1993

#22

Ethical beliefs about burnout and

continued professional practice

USA

Smout et al.,

2022

#23

The influence of maladaptive

coping modes, resilience, and job

demands on emotional exhaustion

in psychologists

Australia and UK

Turnball &

Rhodes., 2021

#24

Burnout and growth: Narratives of

Australian Psychologists

Australia

Vrendenburg et

al., 1999

#25

Burnout in counselling

psychologists: Type of practice

setting and pertinent

demographics.

USA

Williams et al.,

2020

#26

Psychologists' practices, stressors,

and wellness in academic health

centres.

USA

Well-being and Burnout in Psychologists 22

Table 4

Summary of Key Aims, demographics, and methodologies of included papers, in Alphabetical Order, by Author

Paper Aims Design and Participant Findings JBI Risk of Bias and Limitations

ID Method Demographics Score

Examine the level of

burnout and correlates of

burnout.

ANOVA and

Multiple

Regression.

562 Doctoral

Level Licensed

Psychologists

73% Male

27% Female.

Reported that burnedout

clinicians were likely to

be young, low earners,

not engaged in

psychotherapy,

experienced feelings of

lack of control and were

over-involved with client

work.

6/8

Researchers do not state if this

gender split is representative of

the field. Psychologists

experiencing burnout may not

have responded to the request.

Cross-sectional data cannot

provide insight into causation.

Investigate the effects of

gender, personality, job

demands, affective work

rumination and personal-

Hierarchical

multiple

regression

analyses

828 Clinical

Health

Psychologists

78% Female 22%

Male.

Many factors impact

burnout, including

gender, workrumination,

conflict, and exhaustion.

6/8

Inclusion/Exclusion criteria are

not clearly stated, and the period

for data collection is unknown.

Cross-sectional data cannot

provide insight into causation.

Well-being and Burnout in Psychologists 23

to-work conflict on

burnout.

#3 Identify profiles at risk of Hierarchical

burnout. cluster

analysis.

Twoway

ANOVA. 664

Qualified

Age, work

environment

, 7/8

Psychologists and work demands were

9.9% Male all associated with

90.1% Female. burnout in psychologists.

The population of people identifying with neither

gender was not large enough for analysis.

The sample may have overrepresented female

psychologists. Provide findings related to

seniority, but it's unclear what authors classify

seniority.

To explore emotional

labour and burnout in

psychologists who

provide individual therapy.

Thematic

Analysis.

Psychologists

grouped into

Early career

psychologists

(N= 9), Mid-

Career

Psychologists

(N=7) and

Experienced

Psychologists

(N=8)

The increased emotional

intensity of clinical work

is linked to higher levels

of emotional exhaustion

and the need to distance

oneself from workrelated

emotions.

10/10

Did not capture the views of those

who may have left direct clinical

roles due to burnout. The sample

was restricted to western

Australia.

Well-being and Burnout in Psychologists 24

To investigate the

relationships between

burnout, work-setting,

years of experience in that

setting, mindfulness, and

career-sustaining

behaviours (CSBs).

One-way

betweensubjects

ANOVA.

167 Registered

Psychologists

86.8% Female

13.2% Male.

Psychologists with less

time and experience in

their posts have higher

rates of burnout. Increased

mindfulness skills are

linked to lower levels of

burnout.

6/8

Recruitment through registration

bodies may not capture.

Psychologists who have burnt out

and may have left the profession

and no longer hold a professional

registration.

To examine the relationship

between perfectionism,

stress and burnout.

Regression

Analysis.

87 Clinical

Psychologists

86% Female

14% Male

Perfectionism was directly

and indirectly related to

the development of

burnout.

7/8

Relatively small sample, not

adequate to conduct regression

analyses.

To Examine the

contribution of

demographics, workplace

variables, and individual

factors to burnout.

Factor Analysis

and Multiple

Regression.

190 Clinical

Psychologists

71.6% Female

27.9% Male 5%

unaccounted

for.

Being female, working

for the government,

having fewer personal

resources, and having

beliefs about clients were

linked to higher levels of

emotional exhaustion.

7/8

Only 11-34% of the variance of

each burnout scale is accounted

for. Psychologists' level of

cognitive training was not

considered. Can't inform the

direction of the relationship, i.e.,

whether therapist beliefs and lack

of coping resources cause work

stress or vice versa.

Well-being and Burnout in Psychologists 25

To examine the different

experiences of burnout

across Australian

psychologists.

Thematic

Analysis

6 Clinical

Psychologists

Psychologists reported

excessive workload and

hours of work, life

stresses, mismanagement,

and transference between

clients' and their

psychologists as factors

related to burnout.

9/10

Limited sample. Only recruited

participants currently practising,

missed the opportunity to capture

those who may have ceased

practice due to burnout.

No statement locating the

researchers culturally or

theoretically in relation to their

research.

To explore the

Discriminant

1172 Clinical

High burnout was

6/8

Psychologists in this study were

relationship between Early

Maladaptive Schema

(EMS) and burnout.

function analysis

and

Counselling

Trainee

Psychologists

82.3% Female

17.7% Male

associated with a higher

level of physical health

problems and greater

endorsement of all Early

Maladaptive Coping

Styles, but only the

unrelenting standards

were found to be a

significant predictor of

burnout.

not screened for pre-existing

health conditions. The study was

subject to response bias, whereby

participants may have

underreported some EMSs and

endorsed EMSs they perceived as

culturally acceptable— concerns

about being labelled incompetent

etc.

#10

To explore burnout in

relation to social support

Pearson's

correlations

225 Trainee,

newly qualified

Burnout is significantly

related to social support

6/8

Limited sample from a small

geographical area. Inclusion

Well-being and Burnout in Psychologists 26

in private life and

expectations or attitudes

about the profession. To

compare burnout

experiences across varying

professional experience.

and univariate

ANOVA

and experienced

psychologists.

'Roughly equal'

proportions of

Male and

female.

from family and friends

and expectations or

attitudes about the

profession.

/Exclusion criteria are not stated.

Researchers have identified

confounding factors but do not

appear to have controlled for

these during the analysis.

#11

To explore the relationships

between types of humour

and characteristics of job

burnout.

Stepwise

Regression and

Bivariate

Correlation

Analysis

133

Psychologists

68.4% Female

31.6% Male

Self-defeating humour

contributed to higher

levels of emotional

exhaustion and

depersonalisation.

Selfenhancing humour

contributed to higher

levels of personal

accomplishment.

7/8

Using purposive sampling, those

who responded were likely to

have an interest or connection to

the research topic. Relationships

are moderate. Variables needed

to be transformed to perform the

statistical analysis, which may

have affected the outcome.

Causality cannot be determined.

#12

To examine the

relationships between self-

compassion, depression

and burnout.

Hierarchical

linear

regression.

259

Psychologists

40% Female

60% Male

Self-compassion

mediated levels of

burnout and depression in

psychologists. Higher

self-compassion was

linked to lower levels of

6/8

The cross-sectional study design

cannot comment on causality.

There may be other

explanations accounting for the

relationship

burnout and fewer depressive

symptoms.

between burnout, depression, and

self-compassion, not considered

Well-being and Burnout in Psychologists 27

in the research.

#13

To explore the experience

of burnout in sports

psychologists

Thematic

Analysis

30 Sports

Psychologists

Burnout is frequently

experienced despite

psychologists

experiencing high levels

of work engagement—

lower levels of social

support are associated

with higher levels of

burnout.

8/10

No statement positioning the

researchers or exploration of their

impact on the data collection and

analysis.

#14 To identify individual Multiple Linear

variables and job Regression

characteristics that can predict

burnout in Analysis psychologists.

(Stepwise)

518

Psychologists 1 year + postqualification

77% Female

23% Male

The strongest

factors linked

to burnout

dimensions

were

overwork and

emotionfocused coping

strategies. Burnout

occurs due to the

overlap of personal and

work-related variables.

6/8 A cross-

sectional design, which does not allow for

causal conclusions. Again, this highlights

the "healthy worker effect," which may

underestimate the magnitude of the

identified risks.

Well-being and Burnout in Psychologists 28

#15

Examine the levels of job

satisfaction and burnout

among psychologists

working in Irish community

mental health teams

(CMHTs).

Hierarchical

Regression

Analysis and

Thematic

Analysis

Psychologists

76.6% Female

23.4% Male

Relational aspects of

psychologists' jobs and

job satisfaction are

significant factors in the

development of burnout.

6/8

7/10

The low response rate and

consequent small sample size

limit the possibility of generalising

the results in terms of the

representativeness of the wider

population of CMHT

psychologists. The small sample

size also limited the choice of

data analyses that could be used,

prohibiting the reliable testing of

more comprehensive models.

Cross-sectional, no causal

relationships

#16

To examine gender

differences in burnout, work

activities and demands,

and work resources in

independent practice and

agency settings.

Analysis of

Covariance

(ANCOVA) and

Pearson

Correlations.

595

Psychologists

58.3% Female

41.7% Male

Female agency

psychologists experience

higher levels of

emotional exhaustion.

Working in agency

settings is associated

with higher levels of

burnout.

6/8

Did not include psychologists

whose primary work setting was

not clinical. It may have excluded

psychologists who had left clinical

fields due to burnout. Restricted

to clinical and counselling

psychologists may not represent a

wider discipline. Confounding

variables are not fully identified and

explained.

Well-being and Burnout in Psychologists 29

#17

To examine the

relationship between work

setting and burnout

Analysis of

covariance

(ANCOVA) and

Pearson

correlations.

571

Psychologists

54.3% Female

45.7% Male

Higher levels of

emotional exhaustion

were associated with

less control over work

activities, working more

hours, spending more

time on administrative

tasks and paperwork,

and engaging with

challenging clients

7/8

It doesn't define what is meant by

the different work groups. They

also don't explain how they

managed individuals who might

hold dual roles. One criterion was

identified as a clinical setting as

their primary place of

employment; they may not

capture psychologists who have

left clinical settings due to

burnout.

#18

To explore gender and

work-setting interactions

on emotional exhaustion

and work-setting

differences in resources

and demands that relate to

burnout

Analysis of

Covariance

(ANCOVA)

421

Psychologists

57.9% Female

42.4% Male

Family support was

important for workrelated

well-being; however,

conflict between work

and family domains was

associated with burnout.

7/8

The sample was majority white,

based on Eurocentric family

ideas.

Well-being and Burnout in Psychologists 30

#19

To investigate the

relationships between

psychologists' burnout

levels and reflective

practices.

Pearson's

Correlation

120 Qualified

Psychologists

83.3% Female

16.7% Male

Burnout was associated

with the level of job

satisfaction and stress

interacting with clients.

The importance of

adequate supervision

was highlighted as a key

finding.

6/8

The majority of respondents

were from Australia, making it

difficult to generalise to other

countries. Non-experimental

design of this study prevented

the researchers from

establishing causality or creating

a predictive model between RP

and burnout variables.

#20

To examine the work

setting, main sources

of stress, and

prevalence of burnout.

To identify the

predominant Early

Maladaptive Schema's

(EMS) and Maladaptive

Coping Modes (MCM).

Pearson

Correlation and

Hierarchical

regression

443 Fully

registered

clinical and

counselling

psychologists

Coping modes of

detached protector and

detached self‐soother

were most frequently

observed in burnout

psychologists.

6/8

50% of the sample were

Australian. the cross‐sectional

design of this study prevents

attributing causality in the

relationships. The SMI version

used in this study measures only

a small subset of the coping

modes that researchers have

since identified.

#21

To explore factors

contributing to burnout,

specifically, stage of

career.

Consensual

Qualitative

Psychologists

Factors related to

burnout included

challenges with tasks

and responsibilities and

10/10

Participants with extremely

distressing experiences or

neutral experiences may not

have responded to the advert.

Well-being and Burnout in Psychologists 31

influence of maladaptive

coping modes, resilience

and job demands on

emotional exhaustion

Principal- 94

components

Psychologists

factor analysis Pearson

correlational

coefficients

Hierarchical

regression

analyses

425

Counselling

and Clinical

Psychologists

80.7% Female

19.03% Male

Psychologists

who 6/8

believe more strongly

that it is unethical to

practice whilst

experiencing burnout

see fewer clients than

psychologists who

believe this less

strongly.

Maladaptive coping 6/8

modes contribute to the

development of burnout

in psychologists.

The sample was skewed due

to self-selection bias; those

who experienced higher burnout

may have chosen not to

participate. Reliability estimate

was relatively low.

A convenience sample of

psychologists. Cross-sectional, no

implications of causality. The

sample size was adequate, but it

may still have been underpowered

to detect interactions.

#22

To investigate the

relationships between

psychologists' beliefs

of burnout and

experience of burnout.

#23

To understand the

Research

methodology

interpersonal

relationships.

Snowballing, so unable to detail

how representative the sample is.

Researchers with a connection to

the participants completed some

coding.

Well-being and Burnout in Psychologists 32

between burnout and type

of work setting, hours of

client contact, years in

present position, and

years employed with

current organisation

Regression

Analysis

Level

Counselling

Psychologists

64% Female

36% Male

practice reported the

lowest levels of burnout.

Psychologists in hospital

settings reported the

highest levels of burnout.

Working more hours a

week was linked to

higher levels of personal

accomplishment. Lower age

is linked to higher burnout.

psychologists who had left the

profession due to burnout. The

gender split is not representative

of national demographics for

psychologists.

#24

To explore the lived

experiences of

psychologists in relation

to burnout

Thematic

Narrative

Enquiry

Psychologists.

82.4% Female

17.6 Male

Participants described

high workload/ demands,

lack of job clarity,

autonomy, respect, and

personal difficulties as

factors in their

experience of burnout.

9/10

Didn't capture the experiences of

psychologists who had left the

profession due to burnout. There

was a significant difference in the

average age of the groups; the

burnout group were older.

Cultural theories were not used in

the analysis to explore

sociocultural processes.

#25

To examine relationships

Multiple

521 Doctoral

Psychologists in private

6/8

Didn't capture the experiences of

Well-being and Burnout in Psychologists 33

#26 To investigate sources of Between 93 A high workload was 6/8 Modest sample size. Exploratory stress and burnout in

Group ANOVA Psychologists associated with burnout, cannot describe causality. practising psychologists.

67% Female and burnout was Burnout measure was designed

43% Male associated with for the study and therefore has

decreased professional not been validated. satisfaction.

Quantitative

Qualitative Data

Mixed Methods Study

Well-being and Burnout in Psychologists 34

Quality Summary

All papers were rated as high quality. The lowest scores for qualitative

papers were 7/10 and 6/8 for quantitative papers. Across the included papers,

the risk of bias and limitations were commonly noted concerning the

participants. Several studies only recruited psychologists currently registered

or practising clinically, which means that psychologists who had potentially left

their roles due to burnout were not captured in the data (#5, #8, #14, #16, #17,

#21, #24, #25). A lack of a reflexivity statement from the researchers was a

common quality issue for the qualitative papers (#8, #13), while insufficient

detail regarding the management of confounding variables was noted for

several quantitative papers (#9, #10, #16, #25).

Narrative Synthesis

This review aimed to establish the prevalence, causes and factors

related to burnout in psychologists. The thematic synthesis included the

experiences of 8,256 psychologists. Ten initial quantitative themes and five

qualitative themes emerged from the extracted data (Appendix F). The five

overarching themes are presented below (Figure 3).

Well-being and Burnout in Psychologists 41

Figure 3

Summary of the theme merging process

Individual Analytical Themes Overarching Analytical Themes

Presence of Burnout* Presence of Burnout

Demographic Characteristics*

Age and Gender

Quantitative themes are marked with a *

Qualitative themes are marked with a #

Occupational Experiences*

Support Networks

Personal Resources*

Social Support#

Emotional Intensity and impact of the work#

Professional Culture#

Excessive Job Dema

nds#

Work Setting*

Years’ Experience*

Personal Life#

Humour*

Beliefs about Burnout*

Coping*

Support Network*

Occupational Experiences

Personal Resources

SUBTHEMES: Work Setting, Years’

Experience, Emotional Intensity and

Impact of the work, Professional Culture,

Excessive Job Demands.

SUBTHEMES: Humour, Beliefs about

Burnout, coping, personal life

Well-being and Burnout in Psychologists 37

Theme 1: Presence of Burnout

There was a lack of homogeneity of burnout measures used across the

studies, as shown in Table 5. Except for #14 and #19, all quantitative papers

provided information regarding the burnout rate within their sample. The 91

participants in the qualitative studies all self-reported experiencing burnout; however,

this was a criterion for participation.

Table 5

Burnout Measure Information, Presented Alphabetically.

Burnout Measure Dimensions Measured by Tool No. of Paper IDs Papers

Papers not

reporting

prevalen

c e data

Copenhagen

Burnout Inventory

(CBI)

Personal burnout, work-related

burnout, client-related burnout

#5, #6,

#12, #19

#19

Maslach Burnout

Inventory (MBI)

Emotional exhaustion,

depersonalisation, and personal

accomplishment

#1, #3, #7,

#11, #15,

#16, #17,

#18, #22,

#25

N/A

Maslach Burnout

Inventory –

Emotional

Exhaustion Scale

Emotional Exhaustion

#9, #20,

#23

N/A

Shirom-Melamed

Burnout

Assesses exhaustion across physical,

cognitive, and emotional subscales.

N/A

Well-being and Burnout in Psychologists 38

Questionnaire (S

MBQ)

Tedium Burnout Cognitive weariness, fatigue, 1 #10 N/A

Measure (TBM) emotional exhaustion

Job Burnout Enthusiasm toward the job, 1 #14 #14

Syndrome psychological exhaustion, Assessment

indolence, guilt.

Questionnaire

(JBSAQ)

Purpose Four items assessed wellness: two 1 #26 N/A

Designed Burnout addressed burnout, and two

Measure (PDBM) assessed career satisfaction.

The majority of the quantitative papers (#1, #3, #11, #15, #16, #17, #18,

#22, #25) reported average scores for each dimension of burnout compared to

the standardised norms for mental health practitioners, whilst papers #9, #20, and

#23 reported average scores based on general population norms. The remaining

studies reported the number of participants meeting category cut-off scores.

Copenhagen Burnout Inventory. Across the three studies, rates of overall

burnout ranged quite significantly from 8%–30% of the participants; however, for

two studies which reported burnout by category, work-related burnout was

particularly prevalent, with an average of just under 50% (200) of participants

meeting criteria for this (Table 6).

Table 6

Burnout Data from Studies using the CBI.

Well-being and Burnout in Psychologists 39

Paper ID

Levels of Burnout per Dimension

Overall Burnout

Over 35% met the criteria for Personal

Related Burnout.

Over 51% met the criteria for Work-related

burnout.

Less than 15% met the

criteria for overall burnout

Not Reported

8% Met the criteria for

overall burnout

#12

Over 20% met the criteria for Personal

Related Burnout.

Over 42% met the criteria for Work-related

burnout.

30% of participants met

the criteria for overall

burnout

Maslach Burnout Inventory. Though findings around personal

accomplishment and depersonalisation were mixed, participants consistently fell

in either the moderate or high burnout category for emotional exhaustion (Table

7 and figure 4). Only #7 and #25 were limited to one psychological discipline

(clinical and counselling); other papers included Psychologists from a range of

disciplines. The thirteen studies also represented findings encompassing several

countries, including the USA (#1, #9, #11, #16, #17, #18, #20, #22, #23,

#25), Canada (#9, #20), Australia (#7, #9, 20, #23), UK (#9, #20, #23) France

(#3) and Ireland (15). All participants were contacted via their professional

registration body and volunteered to complete online or postal surveys, so

careful consideration of sampling biases weighted towards those with an

invested interest or experience of burnout must be considered alongside findings

relating to prevalence.

Well-being and Burnout in Psychologists 40

Table 7

Burnout Data from Studies Using the MBI Full Scale

Paper

Emotional

Exhaustion

Mean (SD)

Depersonalisation

Mean (SD)

Personal

Accomplishment

Mean (SD)

Level of Burnout using

the standard Norms for

Mental Health

Practitioners

(MBI-MH-S)

19.44 (9.31)

6.31 (4.48)

42.27 (4.52)

EE: Moderate Burnout

DP: Moderate Burnout

PA: Low Burnout

24.50 (8.49)

9.41(3.80)

33.76 (5.13)

EE: High Burnout

DP: High Burnout

PA: Moderate Burnout

Not provided

Below (Stated by the

researcher)

#11

Not provided

Low Burnout (Stated by

the researcher)

#15

15.73 (7.5)

3.15 (2.8)

37.62 (4.91)

EE: Moderate Burnout

DP: Low Burnout

PA: Low Burnout

#16

17.75 (9.16)

4.81 (3.76)

41.56 (4.88)

EE: Moderate Burnout

DP: Moderate Burnout

PA: Low Burnout

#17

19.99 (9.83)

5.21 (4.26)

41.64 (4.78)

EE: Moderate Burnout

DP: Moderate Burnout

PA: Low Burnout

#18

16.41 (8.79)

4.42 (3.69)

42.59 (4.45)

EE: Moderate Burnout

DP: Moderate Burnout

PA: Low Burnout

#22

Not provided

Low Burnout (Stated by

the researcher)

#25

17.83 (8.90)

8.90 (4. 10)

42.09 (4.53)

EE: Moderate Burnout

DP: High Burnout

PA: Low Burnout

Well-being and Burnout in Psychologists 41

Figure 4

Burnout Data from Studies Using the MBI Emotional Exhaustion Scale

90%

80%

70%

60%

50%

40%

30%

20%

10%

SMBQ, TMB, and the Purpose-Designed Questionnaire. 179 of the 828

participants in study #2 scored above the SMBQ cut-off for severe burnout, but

they did not report how many met the criteria for mild-moderate burnout.

The overall level of burnout in study #10 fell in the low-moderate range for the TMB,

with only 14 of the 225 participants in the severe range. 31 of the 93 participants in

study #26 described persistent burnout symptoms on the purpose-designed

questionnaire.

Though there was variation in the overall level of burnout across the

studies, many studies highlighted psychologists experiencing moderate to high

levels of emotional exhaustion, whilst work-related burnout was common amongst

Psychologists completing the CBI.

Moderate Burnout

High Burnout

#20

#23

Well-being and Burnout in Psychologists 42

Theme 2: Age and Gender

Eleven quantitative studies reported findings related to age and gender (Table 8).

Table 8

Findings relating to Burnout, Age and Gender

Paper Burnout Findings Relating to Age Finding Relating to Gender

#25 MBI Age inversely correlated Male Psychologists

reported with EE higher levels of

depersonalisation compared to

female

Younger psychologists report higher levels of EE and may,

Measure

MBI

Younger

Psychologists

experience greater EE

compared to older

colleagues

CBI

Younger

Psychologists

reported higher levels of

burnout

MBI

Higher levels of

EE in women

#16

MBI

Women in agency settings

experience higher EE than

men and women in other

settings

#17

MBI

Women in agency settings

experience higher EE than

men and women in other

settings

#18

MBI

No difference between

burnout in men and women in

agency settings

Well-being and Burnout in Psychologists 43

therefore, be at greater risk of burnout than their older counterparts. This finding

was consistent across studies despite researchers using different burnout

measures and focusing on different burnout dimensions. The studies also covered

a broader range of PPN disciplines, with #1 focused on all

Psychologists with a doctoral qualification, clinical (#6) and counselling (#25)

psychologists; however, the population is limited to North America and Australia.

Results collected using the MBI suggest that women are at a greater risk

of EE than male Psychologists. Women in non-permanent roles, such as

agencies, may be at elevated risk of EE; however, as you can see from table 8,

this finding was inconsistent across studies of participants in the USA (Zippia.,

2023). Notably, 73% of the participants in paper #1 were male. This is three

times higher than North America's national percentage of male psychologists.

Thus, findings may over-represent the experiences of North American male

psychologists. The gender split in all other contributing studies represented their

wider psychological populations.

Theme 3: Occupational Experiences

Subthemes relating to occupational experiences across the qualitative and

quantitative data have overlapping and complementary findings, presented

below.

Work Setting (Quantitative). All the papers used the MBI to measure

burnout; findings are presented in Table 9. Findings suggest that psychologists

working in agency settings and government mental health services may be at greater

risk of burnout than their colleagues in other settings. All studies were conducted with

Well-being and Burnout in Psychologists 44

USA populations, except for #1, which also included Canadian psychologists and #7,

which was conducted with an Australian population.

Table 9

Findings relating to burnout and workplace setting.

Paper ID

Burnout Measure

Finding

MBI

Psychologists in private practice had lower rates of

EE and DP and higher PA than Psychologists in

other settings

MBI

Psychologists in Government mental health

services at an increased risk of EE, DP and PA

#16

MBI

Psychologists working in agencies reported greater

stress and lower levels of PA

#17

MBI

Psychologists working in agencies reported greater

stress and lower levels of PA

#18

MBI

Psychologists working in agencies reported greater

stress and lower levels of PA

#22

MBI

Psychologists in Government mental health

services at an increased risk of EE, DP and PA

#25

MBI

In a comparison of burnout across workplaces:

Psychologists in mental health services have the

highest rates of depersonalisation, private

Psychologists had the lowest rate

Years Experience (Quantitative). This review found evidence that fewer

experienced psychologists experience greater emotional exhaustion and

depersonalisation compared to their more experienced colleagues (#1, #5); however,

Well-being and Burnout in Psychologists 45

no difference in experience was highlighted by paper #10, suggesting a potential role

for inexperience in the role of burnout.

Emotion-Focused Factors (Qualitative and Quantitative). Twelve

papers, six quantitative and six qualitative, highlighted the emotional intensity and

subsequent impact of clinical work as an important factor in Psychologists'

development of burnout (Figure 5).

Figure 5

Graph showing the number of quantitative studies providing evidence for the

relationship between burnout and emotion-focused factors

3.5

2.5

1.5

0.5

0 Conflit Demands

Emotion Focused Coping

Factors

The quantitative data was collected across the MBI, SMBQ, and JDSAQ

and represented several disciplines of Psychologists across Brazil and Ireland, but

primarily North America.

The qualitative data also reflected this theme. Psychologists reported

that high workloads, excessive demands, and insufficient time to complete their

work were all related to burnout. There were several references to psychologists

Well-being and Burnout in Psychologists 46

working over their contracted hours to complete their work on time and

describing their job demands as 'just too much' (Hammond et al., 2018, P.8).

One participant explained the impact of these demands and how it led to their

burnout saying 'I stopped doing things the best I could and just doing things to

get them done’ (McCormack et al., 2015, P.6).

Managing the complex emotions arising from clinical work was a

significant factor in developing burnout.

'what contributes to burnout is seeing clients who really push your

buttons', 'There's that compassion fatigue thing, it's just too much

sometimes'. (Clark et al., 2021, P. 419)

Psychologists' work also appeared to have an impact on their home lives.

Several participants across studies described feeling unable to show their family and

friends the kind of emotional responses that they would like to.

'I'm like a Zombie at the end of the day… I want to have emotion and

show you that, but I've literally got nothing left in the tank'. (Clark et al.,

2021, P. 420)

Professional Culture (Qualitative). Participants across all of the

qualitative studies referred to a lack of discussion and acknowledgement during

their professional training of the risks of burnout in psychologists. One

participant illustrated this by saying, 'They didn't even tell us about burnout…so I

didn't even realise it was something that happened' (Hammond et al., 2018, P.

6).

Well-being and Burnout in Psychologists 47

Similarly, recurrent references were made regarding a lack of discussion about

how to seek support for burnout, with many reporting a stigma around psychologists

asking for help. There were several references to the expectations on psychologists

to 'perform well, be strong, avoid mistakes at all costs, learn from their experiences

and maintain professionalism' (Hammond et al., 2018, p. 6 ). All studies noted that

participants believed the client's needs were more important than their own. This left

many psychologists feeling overwhelmed by their roles and perceived pressure to

perform. Several participants commented on the impact this had on their ability and

willingness to take annual leave, which is captured well by a quote from one

participant who said, 'I felt stressed leading up to my holiday, I felt so guilty about

taking a break from work'.

Theme 4: Personal Resources

Humour (Quantitative). Two studies explored the role of humour in

burnout development, reporting statistically significant relationships. Paper #5

found that maintaining a sense of humour was inversely correlated with overall

levels of burnout, though this association was relatively small. Similarly, paper

#15 explored different types of humour and reported that self-defeating humour

was linked to high emotional exhaustion and depersonalisation levels. There were

some positives associated with humour in this sample. Adaptive forms of humour,

such as affiliative and self-enhancing humour, were highly associated with

personal accomplishment.

Beliefs about Burnout (Quantitative). Only one paper (#23) explicitly

examined participants' beliefs about burnout in relation to their experience. They

found that psychologists who believed more strongly that practising

Well-being and Burnout in Psychologists 48

psychotherapy whilst experiencing burnout was unethical had more knowledge

about preventing burnout and saw fewer clients per week than those who did

not believe it was unethical. They concluded that beliefs about burnout could

impact a person's behaviours at work and, ultimately, their likelihood of

experiencing burnout.

Coping (Quantitative). Amongst the eligible papers, there was a particular

focus on early maladaptive schemas (Bach et al., 2018) and maladaptive coping

modes (MCM)(Simpson et al., 2018) in relation to burnout.

In study #9, the high burnout group reported higher mean scores on all 15

EMSs than the low burnout group. All 15 EMSs significantly predicted

participants' level of burnout more accurately than by chance. Both paper #9

and paper #20 reported that self-sacrifice and unrelenting standards schemas

were the most frequently reported schemas amongst participants with higher

burnout. Paper #20 also reported that all EMSs and MCMs were positively

correlated with emotional exhaustion. Similarly, paper #23 found that each MCM

contributed to predicting participants' levels of emotional exhaustion above the

influence of job demands and resilience.

One paper (#12) explored the relationship between self-compassion and

burnout. Their findings indicated that psychologists with lower levels of

selfcompassion experience higher levels of burnout and more depressive

symptoms. An additional paper (#5) found a strong negative correlation

between the level of burnout and mindfulness, which led them to conclude that

psychologists with fewer mindfulness skills experience higher burnout. This

review suggests that personal factors may play a role in developing burnout.

Well-being and Burnout in Psychologists 49

Several factors were identified, but there were insufficient papers examining

each factor to draw clear conclusions about how important each factor may be.

Personal Life (Qualitative). A clear theme across the six qualitative data

sets related to life outside of participants' work as psychologists, A contributor to

burnout in all groups was personal difficulties and challenges. All the papers

acknowledge that external stressors, personal circumstances or life changes

(such as pregnancy, divorce or transitional ages) were linked to participants'

burnout experiences. One participant summarised the intersection between their

experience of work-related burnout and challenges at home as 'the perfect

storm' (Turnbull & Rhodes., 2021, p. 55).

There is a clear argument that challenges or significant changes in a

person's personal life can impact their risk of developing burnout. It is important

to note that none of the studies collected information on participants' mental

health, which would be a confounding factor in this finding.

Theme 5: Support Networks

Social Support Networks (Quantitative and Qualitative). Three

qualitative papers explored burnout-related social factors, primarily social

support and family-work conflict. Paper #10 found that higher levels of burnout

were associated with less social support, less optimistic expectations, and

higher levels of work-related disillusionment. Regarding work-life balance, higher

work-family conflict was associated with a lower sense of personal

accomplishment, greater emotional exhaustion and depersonalisation of clients.

Three of the core dimensions of burnout, according to the MBI. Discussing work

frustrations with family, friends or colleagues was associated with higher levels

Well-being and Burnout in Psychologists 50

of burnout (paper #5); however, as this study was cross-sectional, it is unclear

whether discussing burnout with others is the cause or effect of burnout.

These findings were complemented by the qualitative findings, which highlighted

the positive significance of the role of the clinical supervisor. Several participants

explained that complicated relationships with supervisors contributed to burnout

as they relied on supervision as a safe and containing space to manage the

difficulties that arose from their work. Without this, the work environment felt

more challenging. Moreover, many spoke of the critical relationship played by

family and friends in managing burnout or avoiding it altogether. This led many

authors to conclude that lacking adequate social support is a risk factor for

developing burnout in psychologists. Interpersonal relationships and the support

networks they provide are important protective factors in psychologists'

experience of burnout.

Cross-Cultural Considerations.

The findings capture the experiences of psychologists working in nine

countries. Their experiences will be impacted by their varied cultural backgrounds,

including different training pathways, healthcare systems and broader socio-

cultural contexts.

Language in Burnout Measures. Cross-cultural considerations may

impact the interpretation of the synthesised data. The conceptualisation of burnout

and the language used to represent and express the concept are particularly

important (Squires et al., 2014). For example, dimensions of the MBI such as

depersonalisation may not exist linguistically or culturally in countries where

English is not the primary language, such as Sweden (#2), Netherlands (#20),

Well-being and Burnout in Psychologists 51

Brazil (#14), France (#3) and the Canadian province of Quebec (#1, #9, #10, #20).

Many of these studies reported using English language outcome measures. This

may impact the rigour of the outcome measure in detecting the prevalence of

burnout across the studies in this review (Maneesriwongul & Dixon., 2004). As

such, the conclusions in this study must be held tentatively and consider the

cross-cultural differences in the language used to define and identify burnout.

Healthcare Systems. There are significant differences in the psychology

and healthcare structures in the USA, Australia and the UK (Papanicolas et al.,

2018), the primary contributors to these themes relating to work settings.

Australia operates a shared public-private system where eligible residents can

access government healthcare free of charge (Duckett & Wilcox., 2015). The

USA has a more complex and primarily private medical system where

government-provided care for eligible individuals is provided at reduced or no

cost (Obama., 2016). On the other hand, the UK has a National Health Service,

free at the point of delivery (Bacon et al., 2022). The difference in how services

are designed, funded and delivered across the study populations will likely

impact the experience of working in a particular professional context. Agency

psychologists in America are likely to experience different stressors than agency

psychologists in Australia, as these agencies provide different services under

varied funding structures. Thus, the term ‘agency’ in this study encompasses a

wide range of working arrangements which differ cross-

culturally.

Psychology Training Pathways. Training pathways vary significantly across

the nine countries. In the UK (Nel et al., 2012) and the USA (Norton et al., 2022),

Well-being and Burnout in Psychologists 52

qualified psychologists usually must complete a doctoral-level qualification. In

Australia, qualified psychologists hold a post-graduate diploma (Norton et al., 2022),

whilst, in Sweden (Allwood et al., 2022) and France (Moser & Rouquette., 2002), an

MSc and proof of experiential learning are accepted for professional registration.

These differences in training experiences are likely to mean that the professional

culture of psychology, the age of newly qualified psychologists and a variety of other

aspects of the experience of psychologists will differ across the countries. Thus

caution must be employed when interpreting these results relating to occupational

experiences, and it must be acknowledged that they represent data from several

distinct professional cultures and not one collective.

Discussion

This systematic review synthesised international data related to the

prevalence, factors and causes of burnout in psychologists. The review findings

suggest that psychologists across North America and Europe may experience

moderate to high levels of emotional exhaustion compared to standard norms for

mental health practitioners. Age, gender and years of experience were all found

to be important factors in the development of burnout. Occupational

experiences, such as job demands and personal resources, such as ways of

coping, also appeared to play an important role. Positive support networks were

critical in minimising psychologists' experience of burnout. Findings are

discussed in the context of existing research and the potential clinical

implications.

Findings suggest that psychologists may experience higher levels of emotional

exhaustion than their mental health colleagues. Given that psychologists often work

Well-being and Burnout in Psychologists 53

with clients experiencing high levels of, this finding is not unsurprising (Rupert &

Dorociak., 2019). Although, some researchers argue that the emotional exhaustion

scale of the MBI is the only sub-scale sensitive enough to capture burnout and, as

such, may account for the higher levels of emotional exhaustion compared to

depersonalisation and personal accomplishment (Smout et al., 2022). Reliably

integrating findings from studies using different outcome measures was a significant

challenge in this review as the dimensions of burnout being measured differ too

significantly to compare,

e.g. emotional exhaustion compared with personal, professional, and workrelated

burnout. As a result, findings are based on just 13 of the total 26 studies which

reported burnout in their samples and must be held tentatively.

None of the eligible studies examined the national prevalence of

psychologist burnout in the UK. Accessible and reliable prevalence data is

essential in understanding the progression of conditions within a population and

planning appropriate, targeted and effective intervention strategies (Fairchild et al.,

2018). The absence of published, peer-reviewed, national prevalence data may

hinder the development of appropriate strategies for preventing and supporting

psychologists experiencing burnout (Ben-Zur & Michael, 2007; BPS, 2020). Future

research may benefit from capturing prevalence data in the UK as an essential

step towards understanding and preventing burnout risk in psychologists in the UK

healthcare workforce.

In other healthcare roles, such as GPs (Abdulla et al., 2011), doctors

(Amoafo et al., 2015), and nurses (Gómez‐Urquiza et al., 2017; MembriveJiménez

et al., 2020) younger professionals are at a greater risk of burnout than their older

Well-being and Burnout in Psychologists 54

counterparts. Our findings were consistent with these reviews. As many eligible

studies were cross-sectional, we cannot explain causation; however, we can use

the Job Demands-Resources Model (Bakker & Demerouti., 2007) to offer one

hypothesis for these findings. Younger psychologists may be more likely to be

experiencing life transitions, which may place greater demands on their resources

(Blair., 2000). Some transitional stages may disproportionately affect females,

particularly childcare responsibilities accounting somewhat for the gender

differences our review observed. Though results were more mixed, female

psychologists, much like their other multidisciplinary colleagues (Hoff & Lee.,

2021), appear at greater risk for burnout than their male colleagues. Psychologists

across the western world work in a wide variety of different settings. Whilst this

review found evidence for the role of age and gender in psychological burnout, it

requires a more nuanced investigation. For example, findings were reported in

binary gender categories, not capturing the experience of the increasing number of

psychologists who identify as non-binary (Richards & Barrett., 2020). Future

research could aim to explore less binary concepts of gender and interactions

between these factors and others, such as age and workplace.

Many of the occupational factors linked to higher levels of burnout in

psychologists were consistent with the research relating to other healthcare

professionals, particularly high workloads, long hours, lacking resources and high

demand (Amoafo et al ., 2015; O'Connor et al., 2018 Patel et al., 2018). Two

subthemes appeared to be more specific to psychologists; professional culture

and the emotional intensity and impact of the work.

Psychology is a highly competitive field. From gaining pre-training experience

securing a place on a training programme (Scior et al., 2014;

Well-being and Burnout in Psychologists 55

Callahan et al., 2018 ), completing rigorous training academic requirements

(Pakenham & Stafford‐Brown, 2012) and working in complex systems

(Kannampallil et al., 2011), psychologists experience pressure throughout their

professional journeys (Cushway and Tyler., 1996). The stressors are well

documented. Given this picture of the psychology field as highly ambitious and

competitive (Ragavan., 2018), it is unsurprising that this review found that

perceived and experienced pressure was a significant factor in psychologists'

experience of burnout. There was also a clear link between engaging with clients

with high levels of distress and higher levels of burnout, with a particular focus

on the negative impact this had on psychologists' ability to manage personal

relationships at home.

These findings suggest that for some psychologists, the very nature of

their work can be a significant risk factor in the development of burnout. As

such, interventions and strategies for burnout prevention could benefit from

more systemic approaches, targeting the psychology profession and

organisations which employ them (Zinsstag et al., 2011). Research tends to

focus on exploring the negative impacts of working with high levels of distress,

such as burnout; however (Sodeke-Gregson et al ., 2013), we must be careful to

acknowledge that, as evidenced by our findings, not all psychologists

experience burnout. Exploring the experience of psychologists who experience

positive work-related well-being could allow researchers to consider what we

can learn from psychologists who are not experiencing burnout. This exploration

could be beneficial in understanding how to best support the workforce's needs.

Review findings supported evidence demonstrating a multidirectional

relationship between burnout and personal experiences (Asanta et al., 2019; De

Well-being and Burnout in Psychologists 56

Hert., 2020), with one participant referring to the interaction as 'the perfect

storm' (Turnbull & Rhodes., 2021, p. 55). Use of humour, beliefs about ethical

practice, and mindfulness were all suggested to be linked to burnout levels;

however, there was not enough data to provide conclusive links in this review.

Far more exploration of these is required to understand their role in developing

burnout.

Social support appears to have positive and negative impacts on

psychologists' experience of burnout. Interpersonal relationships have long been

acknowledged as important sources of social support that can promote

healthcare staff's well-being and mental health (Stubbs & Achat., 2022).

Psychologists perceived positive interpersonal relationships with supervisors as

a mediating factor in developing burnout. Other healthcare professionals have

reported similar findings (Dyrbye & Shanafelt, 2016; Ruisoto. 2021). Much like

their healthcare colleagues, psychologists highlighted interpersonal conflict, with

family, and workplace supervisors, as negatively contributing to their experience

of well-being at work (Lloyd et al., 2002). This is an important finding as

supervision is positioned as a tool to ensure the efficacy and safety of

psychologists' work and safeguard their emotional well-being (Falender, 2018).

Ensuring that high-quality supervision is available for psychologists should be a

priority for employers. However, caution must be given to supervision limitations

as effective prevention, as evidence suggests supervisory experiences improve

disengagement but do not reduce emotional exhaustion (Johnson et al., 2021).

Thus, an integrative approach to burnout, encompassing a range of support, is

likely to be required.

Well-being and Burnout in Psychologists 57

Expansion of Knowledge Base and Clinical Implications

In line with McCormack et al.’s (2018) findings concerning allied

psychological professions, this review suggests that emotional exhaustion is

salient in the experience of burnout for trainee and qualified psychologists. To

the researcher's knowledge, it is the first review to report findings related

explicitly to burnout in this population. By focusing on professional

psychologists, the researchers have identified profession-specific experiences,

such as the emotional intensity of their work and the culture in the psychology

profession, which may contribute to emotional exhaustion in psychologists. This

enables the researcher to make profession-specific recommendations to support

the needs of professional psychologists.

Given that there are arguments for both individual responsibility (West et

al., 2018) and corporate social responsibility (Liu et al., 2023) in preventing and

managing employee burnout, findings indicate that psychologists and those who

employ psychologists may benefit from attending to early signs of fatigue,

apathy and emotional disengagement. Interventions for emotional exhaustion in

front-line healthcare staff should focus on identifying causation factors and

supporting the reduction of symptoms (McFarland & Hlubocky., 2021).

Employers and individuals may wish to consider mindfulness-based

interventions, which have positively impacted emotional exhaustion in the

general workplace population (Hülsheger et al., 2013) and specifically with

healthcare staff (Kriakous et al., 2021).

Findings also suggest that younger and less experienced psychologists may

be at an increased risk for developing burnout. Therefore, it may benefit

Well-being and Burnout in Psychologists 58

psychologists and employers to increase support for and monitoring of

psychologists’ emotional well-being in the pre-qualification and newly qualified

stages. This could be achieved through increased frequency of supervision,

supportive peer spaces for newly qualified psychologists and clear and accessible

pathways for supporting well-being.

Interpersonal conflict and team dynamics may also contribute to

psychologists’ experience of burnout. We must consider this in light of the

knowledge that psychologists are often positioned to mediate team conflict via

reflective practice (Heneghan et al., 2014), which may become an interpersonal

workplace stressor. Again, research exploring the impact of team dynamics

specifically on psychologists would be of benefit; however, employers could

consider outsourcing reflective practice spaces from psychologists outside of their

team to help minimise the emotional impact of this role.

Limitations and Future Research

Grey literature was excluded to support the rigour of the review; however,

many psychologists in training conduct research regarding psychologists'

experience with burnout but do not go on to publish their findings. Future

reviews may wish to include grey literature and adopt a rigorous quality

assessment process to exclude papers of insufficient quality before analysis,

widening the potential pool of eligible studies.

Consideration must be given to the integrated approach to the narrative

synthesis. The researchers followed JBI's advice to qualitise the quantitative data

as codifying quantitative data produces fewer errors than attributing numerating

qualitative data (Stern et al., 2020). Despite this, researchers acknowledge that

Well-being and Burnout in Psychologists 59

qualitising data is a relatively under-researched area and rely heavily on the

researchers' ability to consistently apply their research principles to the

conversion process, which will likely impact the data analysis and interpretation

(Dixon-Woods et al., 2005). Additionally, the findings are based only on the data

reported by the authors of the included papers (Aveyard., 2018). For the findings

drawn from qualitative studies, the researcher's beliefs about the data and

phenomenon of interest will have impacted the interpretation of the findings

(Smith et al., 2021).

Despite many burnout measures having satisfactory validity and reliability

(Kristensen et al., 2005), different tools are likely to report varying levels of

burnout depending on the dimensions they measure. The lack of homogeneity

of burnout measures in this review means that caution must be employed when

considering generalising the findings of this review across populations, settings,

and countries. Future reviews into burnout research may benefit from

considering the most widely used burnout tool in research and clinical settings in

their country of origin to support the generalisability of findings. This could be

incorporated into their inclusion and exclusion criteria.

Conclusion

This review was the first to explore the prevalence and factors related to

burnout in qualified psychologists. Several factors are associated with the

development of burnout, many of which are consistent with burnout for their

healthcare colleagues; psychologists may experience additional risk factors due

to the emotional intensity and impact of their work and the culture of the

psychology profession. Psychologists may experience moderate to high levels

Well-being and Burnout in Psychologists 60

of emotional exhaustion burnout linked to their occupation; however, providing

an accurate overall prevalence is challenging due to vast differences in how

prevalence data is collected and reported.

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Appendices

Appendix A: PRISMA Checklist With Locations

(Adapted from Page et al., 2021)

Section and

Topic

Item

Checklist item

Location where the item is reported

TITLE

Title

Identify the report as a literature review.

Title Sheet

ABSTRACT

Abstract

Provide a structured summary including, as applicable: background; objectives; data sources; study eligibility

criteria, participants, and interventions; study appraisal and synthesis methods; results; limitations; conclusions and

implications of key findings.

See the PRISMA 2020 for Abstracts checklist for the complete list.

Abstract Section

INTRODUCTION

Rationale

Describe the rationale for the review in the context of existing knowledge, i.e., what is already known about your

topic.

Provided in the background literature

review

Objectives

Provide an explicit statement of the objective(s) or question(s) the review addresses with reference to participants,

interventions, comparisons, outcomes, and study design (PICOS).

Provided in the reeview aims and

objectives and methods.

METHODS

Eligibility criteria

Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses with

study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language,

publication status) used as criteria for eligibility, giving rationale.

Provided in the method sections

Information

sources

Specify all databases, registers, websites, organisations, reference lists and other sources searched or consulted

to identify studies. Specify the date when each source was last searched or consulted.

Methods sections and appendices

Search strategy

Present the full search strategies for all databases, registers and websites, including any filters and limits used.

Methods and Appendices

Well-being and Burnout in Psychologists 84

Selection process

State the process for selecting studies (i.e., screening, eligibility).

Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many

reviewers screened each record and each report retrieved, whether they worked independently, and if applicable,

details of automation tools used in the process.

Covered in the methods section

Section and

Topic

Item

Checklist item

Location where the item is reported

Study risk of bias

assessment

Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how

many reviewers assessed each study and whether they worked independently, and if applicable, details of

automation tools used in the process.

Covered in methods and findings

RESULTS

Study selection

16a

Describe the results of the search and selection process, from the number of records identified in the search to the

number of studies included in the review, ideally using a flow diagram.

Methods

16b

Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were

excluded.

Methods and Prisma flow chart

Study

characteristics

Cite each included study and present its characteristics (e.g., study size, PICOS, follow-up period).

Summaries in key information table

Risk of bias in

studies

Present assessments of risk of bias for each included study.

Presented in the table and in the quality

assessment summary paragraph

Results of

individual studies

For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an

effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots. Clearly

represent which studies have identified which findings, and offer transparency around the use of outcomes

measures, country of origin, and training background of participants

Covered in methods and discussion

DISCUSSION

Discussion

23a

Provide a general interpretation of the results in the context of other evidence.

Discussion

23b

Discuss any limitations of the evidence included in the review.

Limitations and future research

23c

Discuss any limitations of the review processes used.

Limitations and future research

23d

Discuss implications of the results for practice, policy, and future research.

Limitations and future research

OTHER INFORMATION

Well-being and Burnout in Psychologists 85

Registration and

protocol

24a

Provide registration information for the review, including register name and registration number, or state that the

review was not registered.

Review not registered, not a

requirement at time of understaking the

review

24b

Indicate where the review protocol can be accessed, or state that a protocol was not prepared.

Review not registered, not a

requirement at time of understaking the

review

24c

Describe and explain any amendments to information provided at registration or in the protocol.

Review not registered, not a

requirement at time of understaking the

review

Section and

Topic

Item

Checklist item

Location where the item is reported

Support

Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the

review.

N/A for Dclin

Competing

interests

Declare any competing interests of review authors.

N/A for Dclin

Availability of

data, code, and

other materials

Report which of the following are publicly available and where they can be found: template data collection forms;

data extracted from included studies; data used for all analyses; analytic code; any other materials used in the

review.

Full titles and authors of papers are

provided

Well-being and Burnout in Psychologists

Appendix B: Full Search Terms

Database

Terms

MEDLINE

PsychInfo

Webb of Science

1 ("burnout" and

"psychologist*" and (stress* or

"emotional exhaustion*" or

pressure or coping or manage* or

"well-being" or "mental health" or

"work related stress" or

"compassion Fatigue"))

1 ("burnout" and

"psychologist*" and

(stress* or "emotional

exhaustion*" or pressure

or coping or manage* or

"well-being" or "mental

health" or "work related

stress" or "compassion

Fatigue")).

1 "burnout"

2 Limit 1 to'll adult (19 plus

years)

2 limit 1 to

"300 adulthood <age 18

yrs and older>"

2 Psycholigist*

3 Burnout, Psychological/*

3 exp Occupational

Stress/*

3 (stress* OR "emotional

exhaustion*" OR

pressure OR coping OR

manage* OR "wellbeing"

OR "mental health" OR

"work related stress" OR

"compassion

Fatigue")

Well-being and Burnout in Psychologists

4 Occupational Stress/*

4 exp Psychologists/*

4 1, 2 and 3

5 3 and 4

6 1 or 5

7 Limit 6 to "all adult (19 plus

years)"

7 Limit 6 to

"300 adulthood <age 18

yrs and older>"

Results

/* Database specific MeSH terms

Well-being and Burnout in Psychologists 93

Appendix C: Sample of the Extraction Table

Part 1

Well-being and Burnout in Psychologists 94

Well-being and Burnout in Psychologists

Appendix D: JBI Checklist for ACS

Item

Question

Were the criteria for inclusion in the sample clearly defined?

Were the study subjects and the setting described in detail?

Was the exposure measured in a valid and reliable way?

Were objective, standard criteria used for measurement of the

condition?

Were confounding factors identified?

Were strategies to deal with confounding factors stated?

Were the outcomes measured in a valid and reliable way?

Was appropriate statistical analysis used?

Comments:

Response Options: Yes, No, Unclear or Not Applicable

Well-being and Burnout in Psychologists

Appendix E: JBI Checklist for Qualitative Research

Item

Question

Is there congruity between the stated philosophical perspective and the

research methodology?

Is there congruity between the research methodology and the research

question or objectives?

Is there congruity between the research methodology and the methods

used to collect data?

Is there congruity between the research methodology and the

representation and analysis of data?

Is there congruity between the research methodology and the

interpretation of results?

Is there a statement locating the researcher culturally or theoretically?

Is the influence of the researcher on the research, and vice- versa,

addressed?

Are participants, and their voices, adequately represented?

Is the research ethical according to current criteria or, for recent

studies, and is there evidence of ethical approval by an appropriate

body?

Do the conclusions drawn in the research report flow from the analysis,

or interpretation, of the data?

Comments:

Response Options: Yes, No, Unclear or Not Applicable

Well-being and Burnout in Psychologists 97

Appendix F: Summary of Thematic Synthesis Theme Development for Quantitative Data

Analytical

Theme

Descriptive Theme

Example Codes

Example Quotes

Presence of

Burnout

Burnout Outcome

Measures

Lower than standard norms, higher than standard

norms, sever/ high burnout, mild burnout,

moderate burnout, high emotional exhaustion,

high depersonalisation, low personal

accomplishment.

‘Mean emotional exhaustion (EE), depersonalisation (DP) and

personal accomplishment (PA) were significantly higher than

MBI standards for mental health workers’, ‘49.2% of

participants scored in the high burnout range’

Demographic

Characteristics

Age and Gender

Women, men, older psychologists, younger

psychologists, age.

‘Younger psychologists scored higher on EE than older peers’,

‘…correlations indicated that younger age was related to higher

burnout.’, ‘Females had significantly higher personal burnout.’

Occupational

Experiences

Work Setting, Years’

Experience and the

Impact of the Work

Early career psychologists, newly qualified

psychologists, private practice, agency

psychologists, job satisfaction, caseload,

relationships with colleges, job demands,

roleconflict.

‘Role conflict was positively correlated with disengagement.’,

‘Psychologists in private practice experienced less emotional

exhaustion, less depersonalisation, and more personal

accomplishment’

Personal

Resources

Humour, Beliefs about

Burnout and Coping

Self-defeating humour, self-enhancing humour,

positives associated with humour, believe burnout

‘Unrelenting Standards Early Maladaptive Schemas were most

highly endorsed by both the low and high burnout group’,

Well-being and Burnout in Psychologists 98

is unethical, maladaptive coping modes, early

maladaptive schema, self-sacrificing

‘Self-defeating humour (β = .32, p < .001) had the biggest

negative impact on psychologist’s burnout’

Social Support

Networks

Talking to Family and

Friends

Less social support, work-family conflict, talking to

friends, discussing frustration with family.

‘Discussing work frustrations with family, friends or colleagues

positively correlated with overall burnout’, ‘greater burnout

was associated with less social support’

Well-being and Burnout in Psychologists

SCHOOL OF PSYCHOLOGY

DOCTORATE IN CLINICAL PSYCHOLOGY

Empirical Research Project

Well-being and Clinical Psychology Training: An exploration of clinical

psychologist’s learning experiences through clinical training and the

impact post-qualification.

Trainee Name: Amy Claire Peters

Primary Research Supervisor: Dr Cordet Smart

Secondary Research Supervisor: Dr Rachel Handley

Target Journal: British Journal of Clinical Psychology

Word Count: 11,773 (excluding abstract)

Submitted in partial fulfilment of requirements for the Doctorate Degree in Clinical

Psychology, University of Exeter

Well-being and Burnout in Psychologists 99

Abstract

Background: Clinical psychologists (CPs) can experience poor wellbeing

due to their professional demands (Bettney., 2017). Clinical psychology training

programmes must support CPs in developing their ability to manage their well-

being (Myers et al., 2012 BPS., 2017); however, to the researcher’s knowledge,

no research explores CPs' experiences of learning about well-being through

training. Thus, the current study aims to address this gap and explore the impact

of this learning post-qualification.

Methods: Twelve recently qualified clinical psychologists participated in

semistructured interviews exploring their well-being-related learning experiences

during training. Transcripts were analysed using interpretive phenomenological

analysis (IPA) to generate key themes.

Findings and Discussion: Four key themes were identified across participants’

experiences. These were: implicit messages about well-being, wellbeing is not

prioritised, connection maintains well-being and inadequate preparation for

post-qualification challenges. Findings highlight the importance of organisational

culture and implicit communication in CPs' learning experiences.

Clinical Implications: Course providers should carefully attend to what and how

messages about well-being are communicated to trainee CPs during training to

maximise opportunities to prepare CPs to take a sustainable approach to their

well-being.

Keywords: Well-being, Clinical Psychology, Clinical Psychologists, Training,

Meaning Making

Well-being and Burnout in Psychologists 100

Introduction

Clinical psychologists (CPs) are susceptible to poor well-being due to

workrelated stressors, including large caseloads, insufficient staffing, and the

emotional impact of working with clients experiencing emotional distress (Myers

et al., 2012; Bettney., 2017). CP’s well-being warrants investigation for several

reasons. Firstly, it can have profound psychological consequences, including

burnout, depression, and anxiety (Jones & Thompson., 2017; McCormack.,

2018; Richardson et al., 2020). There may also be adverse consequences for

patient safety, with poor well-being linked to increased clinical errors (Hall et al.,

2016). Lastly, many CPs are leaving the NHS workforce and stating workrelated

stressors, unsustainable working conditions and poor work-life balance as

reasons for leaving (Ahmed et al., 2022; Shemtob et al., 2022). With a 14%

vacancy rate for NHS CP posts (HEE., 2021; Deakin, 2022), well-being presents

a significant concern in ensuring the NHS is sufficiently staffed to meet the ever-

increasing demand for services (Baker., 2020; HEE., 2021).

Given the significant impact of staff well-being and the emotional impacts

of COVID-19 on healthcare workers, it is unsurprising that the NHS has faced

increased pressure to support the well-being of their workforce (The Kings Fund.,

2018; Clarkson et al., 2023). Individual clinicians are also being encouraged to

proactively manage their well-being (Bettney., 2017; Walker., 2017). Historically,

research on CP well-being focused on identifying workrelated stressors and

developing interventions to improve well-being (Cushway, 1992; Hannigan et al.,

2004; Pakenham & Stafford‐Brown., 2012; Pakenham., 2015). CPs complete a

rigorous doctoral training programme that presents opportunities for varied and

Well-being and Burnout in Psychologists 101

immersive learning in various areas, including personal and professional

development, such as well-being (British

Psychological Society, BPS., 2017). Currently, no research explores CP's

wellbeing-related learning during this period. Thus, the current addresses this

gap by exploring CP’s experiences of learning about well-being during training

and the impact of this learning post-qualification.

Defining Well-being

Staff well-being has become a key consideration in occupational health

due to the recognition of its relationship to workplace productivity and staff

retention (Simons & Baldwin., 2021). There is a lack of consensus on the

definition of well-being (Forgeard et al., 2011; Dodge et al., 2012; Simons &

Baldwin., 2012); however, it is generally accepted that it is a state in which an

individual experiences positive feelings, growth, and a sense that they can meet

their potential in a given environment (Simons & Baldwin., 2021). It

encompasses biological, social, and psychological factors such as demands

and resources (Dodge et al., 2012) and can fluctuate over time. An integral

concept of well-being is a desire to achieve equilibrium or stasis (Cummins.,

2010).

A historical review of occupational well-being models is provided by

Schmidt and colleagues (2019); however, the Job-Demands Resource Model (J-

DRM) is often cited as a helpful way to operationalise workplace well-being in

healthcare settings(Bauer et al., 2014). The J-DRM suggests that occupational

experiences can be divided into two categories. The first, Job demands, refers to

the aspects of one's role that require sustained effort (such as high workloads)

Well-being and Burnout in Psychologists 102

and are associated with biological, psychological and social costs (Bakker and

Demerouti, 2017). Personal resources are the second category, which refers to

aspects of the job that help to support one's ability to reach work-related goals

and improve their occupational experience. Job and personal resources (such

as relationships with colleagues and optimism) work to reduce the costs

associated with job demands and stimulate personal growth (Demerouti et al.,

2001; Xanthopoulou et al., 2009). Although the J-DRM receives criticism for lack

of distinction between processes, such as what constitutes a demand or

resource or the role of internal motivation (Taris & Schaufeli., 2018), the model

provides a robust conceptualisation of well-being for occupational research

(Schaufeli, 2017).

Well-being in Clinical Psychologists

Historically, psychologists neglect the importance of developing and

maintaining a balance between caring for others and the self (Wise et al., 2012).

This is reflected in research indicating that CPs are at high risk of experiencing

work-related distress and burnout (Lee et al., 2011; Bettney., 2017). During training,

competing clinical, research, and academic demands, alongside the anxiety caused

by constant evaluation, have been consistently shown to impact trainee CP’s well-

being negatively (Cushway., 1992; Hannigan et al., 2004; Pakenham & Stafford-

Brown, 2012; Pakneham., 2015).

Trainee CPs must inevitably transition from students to qualified

practitioners, which can be a challenging period for the well-being of healthcare

professionals, including CPs (Van Den Broek et al., 2020; Levinson et al., 2021).

According to Melesis Transition Theory (Meleis et al., 2010), healthcare workers

Well-being and Burnout in Psychologists 103

may experience disconnection from previous social or organisational support

structures, loss of reference points, new responsibilities, and increased

autonomy when transitioning to qualified practice. Understanding the potentially

stressful experience of transitioning from a trainee to a qualified CP is important

in understanding how the well-being of CPs may change over time and

identifying periods that may pose a more significant threat to CP's well-being. It

may also help to identify opportunities for meaningful intervention, which may be

beneficial targets for explorative research (Levinson et al., 2021). Once

qualified, CPs continue to experience stressors now relating to job demands,

large caseloads, and working in isolation (Myers et al., 2012; Bettney., 2017).

Supporting clients experiencing emotional distress can lead to the experience of

vicarious trauma, the negative effects of which are well documented (Lim et al.,

2010; Makadia et al., 2017). Research has highlighted that many psychologists

are experiencing burnout and report significant challenges in maintaining work-

life balance (McCormack et al., 2018). Maintaining well-being and engaging in

self-care can help to reduce the risk of burnout in CPs (Rupert & Dorocaik.,

2019). The current provision of well-being learning opportunities on DClinPsy

courses may unwittingly contribute to a professional culture in which

psychologists struggle to connect with a need to prioritise their well-being (Wise

et al., 2012). With recently qualified CPs at continued risk of poor well-being, we

must fully understand the role of this highly formative clinical training period

(BPS., 2019) in preparing CPs to manage their well-being throughout their

careers. Maintaining well-being and engaging in selfcare can help to reduce the

risk of burnout in CPs (Rupert & Dorocaik., 2019). The current provision of well-

Well-being and Burnout in Psychologists 104

being learning opportunities on DClinPsy courses may unwittingly contribute to a

professional culture in which psychologists struggle to connect with a need to

prioritise their well-being (Wise et al., 2012).

Upon completing the doctorate, many CPs continue to work in the NHS

(Odusanya et al., 2018). Most recent figures published in 2019 showed that

20,000 psychological professionals worked within the NHS, with CPs accounting

for over 42% of the psychological profession's workforce (HEE., 2021). The

demand for psychologists is increasing, with plans to train and recruit 2,520

additional psychologists into the workforce by 2024 (HEE., 2021). Though poor

well-being has become an increasing concern for CPs throughout their careers,

those at an early career stage or in training may be particularly susceptible

(Pakenham & Stafford‐Brown, 2012; Rose et al., 2019). To support the

expansion of the CP workforce, it is fundamentally important that we understand

more about CPs' experience of learning about well-being in the early stages of

their careers, including training and the transition into postqualification.

Clinical Psychology Training, Learning, and Well-being

To become a CP in the UK, individuals complete a three-year Doctorate in

Clinical Psychology Programme (DClinPsy) in one of the 30 approved training

institutions. The training follows a competency-based training model to support

the development of doctoral standard academic, clinical and research skills

(Kenkel & Peterson., 2010). Trainees are also required to meet an appropriate

level of personal and professional development (Nel et al., 2012).

The DClinPsy is a post-graduate adult learning experience which utilises

formal and informal experiential work-based learning (Costley & Lester., 2012; Nisbet

Well-being and Burnout in Psychologists 105

et al., 2013). Learning occurs through attendance at clinical placements, formal

learning (e.g., university lectures and workshops) (Choi and Jacobs,

2011), and independent learning through completing a research thesis (Nel et al., 2012). In

preparing CPs for NHS careers, training programmes must provide structured opportunities for

strategy development for well-being (Gockel., 2010; Pakenham & Stafford-Brown, 2012). Of the

nine core competencies and 71 sub-competencies for CPs in training, only two sub-

competencies recognise the importance of trainee well-being. The BPS does not provide

specific directions on how to support trainee CPs to meet these well-being-related

competencies (BPS., 2017). As such, CP's learning experiences will likely vary significantly

across DClinPsy courses. Literature searches did not reveal any research exploring what CPs

learn about well-being during training (BPS., 2017); however, research does suggest that

training programmes do not adequately support trainee CPs to develop strategies for well-being

maintenance (Lambert & Simon, 2008; Myers et al., 2012; Brettney., 2017). Despite there being

a role for DClinPsy courses in supporting CPs to learn about well-being, the paucity of research

exploring the learning experiences of CPs presents a significant gap in the research

understanding of the impact of training on CP's well-being throughout their careers.

Individuals' learning experiences are shaped by their pre-conceived

assumptions, knowledge and experiences, which are heavily influenced by their

experience of the world. Through learning, individuals attempt to understand and

give meaning to their experiences (Billett, 2008; Nevalainen et al., 2018). During

the DClinPsy, each trainee CP experiences individualised learning; however, for

NHS staff, Organisational culture (OC) can enhance or inhibit their learning

experience (Davies & Nutley., 2000). OC refers to ways of thinking, feeling, and

behaving shared by individuals in a healthcare organisation

Well-being and Burnout in Psychologists 106

(Mannion & Davies., 2018). Culture is a fundamental part of the stories and narratives

organisations, teams, and subsequently, individuals learn to hold about why things are done in a

certain way (Simpson et al., 2019). It provides individuals with guidance on how they are

expected to think, feel and behave in relation to a range of topics, such as well-being

(Nanayakkara & Wilkinson., 2022).

According to Schein (1990), there are three levels of OC, which help to

demonstrate the potential impact of OC on CP's experiences of learning about

well-being. Artefacts are the shallowest indicator of OC; they refer to the visible

indicators of culture, such as dress codes, banding or role titles, and office

layouts (Davies 2002; Mannion & Davies., 2018). Organisational values, mission

statements, and written communications are all examples of espoused values.

These are deeper aspects of OC that would create some noticeable change to

overall OC in an organisation such as the NHS (Scott et al., 2003).

The deepest and arguably most important aspect of OC, according to Schein

(1990), comes from underlying beliefs and assumptions; these reflect

individually held assumptions about how employees should perform, interact

with others, and conduct themselves. These are the strongest indicator of what

an organisation is like; they are often held by the individual, hard to access, and

even more challenging to influence (Al Saifi., 2015). These aspects of OC can

significantly impact the overall content and process of the learning experience

for healthcare workers (Davis & Nutley., 2000).

During their training, CPs are uniquely positioned as they experience their

learning within the context of two large organisations, the NHS and their host

university. The NHS culture for frontline staff has long been characterised by the

Well-being and Burnout in Psychologists 107

expectation to start work early, finish late, and to subjugate one's needs for the

needs of the patients (Mackenzie., 1995). In addition, emotional stoicism, or the

tendency to endure hardship without complaint, or external expression of the

distress caused, is highly valued in the NHS culture (McCarthy et al., 2020). The

OC relating to senior management in UK universities has received some

research attention (O’Connor., 2011); however, the review of the evidence

provided little research exploring the student experience of OC at UK

universities. There are several reported similarities in the culture across the NHS

and Universities in the UK; for example, due to an increase in the use of national

frameworks, focus on auditing, and producing outcome and performance data,

both incorporate aspects of a hierarchical culture (Jacobs et al., 2013). As OC is

such a nuanced element of organisational life, there are likely differences or

conflicts in the underlying beliefs and assumptions held by individuals across

these organisations (Sagiv & Schwartz., 2007), which CPs will experience in

their well-being learning journey. Adapting to and integrating the experience of

university and NHS cultures is not dissimilar to the notion of acculturation

(Thacker et al., 2022). Acculturation refers to the process in which people adapt

to the dominant culture in a specific environment while retaining some of their

cultural values and beliefs. Though this is often used in relation to the

experiences of people from multicultural backgrounds, it is helpful to consider

this process concerning the learning experiences of CPs during clinical training.

OC is both an individual and group phenomenon. The individual aspect of

OC, which is concerned with the sense-making of the individual in relation to

aspects of culture, such as the impact of underlying assumptions and beliefs, is

Well-being and Burnout in Psychologists 108

often overlooked but is, in fact, imperative in the manifestation and maintenance

of OC (Harris., 1994; Dougherty & Smythe., 2004). Based on this, it is

reasonable to suggest that an exploration of CP's learning experiences relating

to well-being, and the OC context in which they take place, could be beneficial

in further understanding CPs' learning and ongoing maintenance of their

wellbeing. Moreover, understanding the culture around well-being is essential in

creating change to unhelpful aspects of OC (Scott et al., 2003).

Interpretive Phenomenological Analysis

Well-being is arguably an individual learning experience which occurs in

a wider cultural context. For CPs, the underlying beliefs and behaviours they are

exposed to in their OC and subcultures will likely influence their sensemaking

experiences in the learning process (Mahler., 1997). In their review of best

practices for DClinPsy learning, Nel and colleagues (2012) argue that a

qualitative approach to research utilising semi-structured interviews is required

to obtain a more in-depth understanding of CPs' lived experiences of learning

during clinical training.

IPA is a qualitative analysis method that, by focusing on an individual’s

sense–making, provides an ideographic approach to exploring specific events or

experiences (Alase., 2017). IPA allows researchers to present interpretive

findings which may be transferable to an appropriately homogenous group of

CPs in the UK (Smith et al., 2022). Therefore, IPA is an appropriate method of

analysis for the proposed research as it allows the researcher to draw out the

ideographic learning experience related to well-being, including consideration of

Well-being and Burnout in Psychologists 109

underlying beliefs and assumptions. Simultaneously, it allows for consideration

of the broader cultural impact on CPs sense-making experiences (Smith et al.,

2022).

The Rationale for the Current Research

This brief review of the literature illustrates that CPs are highly trained

and highly-skilled assets which are critical in the composition of the

psychological professions workforce and delivery of NHS services. Despite a

vast body of research detailing CP's experiences of poor well-being, and the

adverse consequences of this, there is an absence of research which explores

what and how UK-trained CPs learn about well-being through training. This

research aims to address this gap by exploring the well-being learning

experiences of CPs during training and the subsequent impact of this learning on

their post-qualification experiences.

This exploration may have several benefits. Firstly, it expands the current

research field beyond identifying work-related stressors and the subjective

wellbeing experience and into the somewhat overlooked area of well-being

learning experiences. Moreover, it shines a light on the lived experience of CPs

in learning about well-being, with a particular emphasis on what it is like to

experience this learning in the context of the beliefs and assumptions held by

organisations such as the NHS and DClinPsy host universities. The

research may enable researchers to make recommendations to course

providers to ensure that training programmes maximise the learning opportunity

to prepare CPs to manage their well-being throughout their NHS careers

sustainably. In addition, understanding the impacts on their early

postqualification experiences of well-being would be beneficial in understanding

Well-being and Burnout in Psychologists 110

how this learning is carried into their post-qualification experiences and provides

similar opportunities for recommendations to NHS trusts supporting newly

qualified CPs in their transition to qualified practice.

To achieve these aims, the researchers intend to answer the following research

questions:

1. What are clinical psychologists' experiences of learning about well-being

during training?

2. How does this learning impact clinical psychologists' experience of wellbeing

post-qualification?

Method

Methodology

The researcher is aligned with a cultural relativist stance, which dictates

that there is no one truth (Thomas & Yahix., 2016). The researchers believed

that each CPs' sense-making would be based on their societal context and could

change over time (Peat et al., 2018). An emic epistemology was selected to

underpin the research, allowing the researchers to explore CPs' experiences of

learning about well-being through the participant's perspectives, beliefs and lived

experiences.

Ethical Approval

Ethical approval was granted by the University of Exeter Psychology Ethics

Committee (Appendix A). Participation was voluntary. Participants were able to

able to withdraw up to one month after their interview. After this time, participant

data were anonymised, and the link document was destroyed.

Well-being and Burnout in Psychologists 111

Participants

Clinical Psychologists who graduated from a UK-based Doctorate in Clinical

Psychology course in the last two years (between 2018 and 2020) were invited to

participate. The BPS does not define the ‘newly qualified period for CPs, so this

time frame was chosen as it would capture newly qualified psychologists able to

recall their training and newly qualified experiences in detail required for the study.

Recruitment

Participants were recruited via Facebook and Instagram using a research

poster (Appendix B) posted in groups specifically for CPs or related to clinical

psychology (Appendix C). Participants who expressed interest via email were

sent the participant information sheet (Appendix D) and encouraged to email the

researcher with any questions.

Participants completed a consent form (Appendix E) and a demographic

questionnaire via Qualtrics (Appendix F). Demographic characteristics (age,

gender, ethnicity and sexual orientation) were collected to enable comparison with

national data. Many CPs work with their training course providers

postqualification. To ensure participants could express their experiences fully, they

were not asked to report their training course; however, during transcription,

researchers identified that each participant completed their training at a different

training programme.

The interview was arranged via email, and the participants were sent a

Zoom link to a secure virtual room. Twelve participants completed the interview;

however, one participant's data was removed from the before analysis due to

issues with the recording quality.

Well-being and Burnout in Psychologists 112

Table 1

Participant Characteristics

Participant

Age

Gender

Identity

Ethnicity

Sexual

Orientation

26-

Woman*

White – British *

Heterosexual

18-

Woman*

White – British *

Heterosexual

26-

Woman*

White – British *

Prefer not to say

26-

Woman*

White – British *

Heterosexual

35-

Woman*

White -Irish

Heterosexual

26-

Woman*

White – British *

Bisexual

26-

Woman*

White – British *

Heterosexual

26-

Woman*

White – British *

Heterosexual

26-

Woman*

White – British *

Heterosexual

P10

26-

Woman*

White – British *

Heterosexual

P11

35-

Woman*

Black / Black British/ Caribbean/

African

Heterosexual

P12

26-

Woman*

White – British *

Heterosexual

*Including transgender woman

* Including English/ Welsh/ N Irish and Scottish

Grey indicated the participants whose data was removed

Well-being and Burnout in Psychologists 113

Design

The study utilised individual semi-structured interviews, and Interpretive

Phenomenological Analysis (IPA) was used to analyse the data and generate themes

related to the participant's meaning-making experiences.

Semi Structured Interviews

Interview Schedule

A semi-structured interview schedule (Appendix G) was developed in four

stages:

1. Existing literature was reviewed alongside the research questions, and

questions were drafted.

2. The draft schedule was shared with the research team, a senior research

associate at an independent university, and a clinical psychologist and

academic tutor on a clinical psychology doctorate programme.

3. Edits, including the addition of prompts (e.g., ‘could you say more about how

you learned X?’) and making questions more specific to focus on the

experience of well-being (e.g., can you tell me about your well-being journey

as a CP? were made to improve the schedule.

4. A pilot interview was completed with a newly qualified CP with less than one

year of post-qualification experience. Minor amendments were made to

improve flow and generate prompts (e.g., asking participants to consider

different types of learning, such as formal, informal, etc.).

Well-being and Burnout in Psychologists 114

Procedure

Participants joined the interview using the zoom link provided. Before starting the audio

and video recording, participants were reminded of the following:

1. The research aims and given another opportunity to ask questions.

2. Their right to choose not to respond to any question without providing a reason and to

stop the interview at any time without reason.

3. The removal of identifiable data at the transcription stage.

Interviews lasted approximately 60 minutes. At the end of the interview, the

recording was stopped, and participants were given time to ask any final

questions related to the project and debrief informally with the researcher. After

the interview, participants were emailed the debrief sheet (Appendix H) and a £15

Amazon voucher.

Methods of Analysis

Consideration of Analysis Method

The researchers considered several methods of analysis consistent with

the epistemological stance. Narrative analysis would have enabled the

exploration of CP's meaning-making by exploring the language they used to

construct their stories (Herman & Vervaeck., 2019), whilst discourse analysis

would have supported an exploration through CPs language-in-use (Paltridge.,

2021). Ultimately, IPA was chosen to explore well-being through CPs

sensemaking experiences (Smith et al., 2021), which felt best suited to exploring

the emotional experience of learning about well-being (Colville et al., 2016), and

the ideographic experience of beliefs and assumptions related to OC. An

Well-being and Burnout in Psychologists 115

ideographic approach allows the researchers to explore how CPs' beliefs about

well-being are shaped by their actions and experiences and how these continue

to shape future beliefs (Murphy, 2021). IPA is well suited to analysing small

homogenous samples where participants have direct experience of the

phenomena of interest (Peat et al., 2018), and is beneficial for analysing data

with limited prior evidence in the field, as in this study (Creswell & Creswell,

2017).

IPA draws from three philosophical concepts: ideography, phenomenology

and hermeneutics. Ideography is the cornerstone of IPA and underpins the

researcher's epistemological stance. An ideographic approach to analysis

enabled the researchers to shift the focus away from attempts to generalise the

well-being experiences of CPs across the UK and instead champion the

importance of understanding the individual lived experience (Smith., 2022).

Ideography helped generate findings that may be transferable to the wider

experience of some trainees but do not claim to prove or disprove the group's

experience as a whole (Biggerstaff & Thompson., 2008).

Phenomenological principles were applied through the consideration of

the CPs' perspective on their experiences learning about well-being, particularly

their embodied experiences and how they make sense of their relationship to

learning, well-being, clinical training and post-qualification (Miller et al., 2018);

Love et al., 2020). Finally, the double hermeneutic, which refers to the impact

researcher’s attempts to make sense of the CPs own sense-making experiences

has on the interpretation of data, was particularly important to consider in this

Well-being and Burnout in Psychologists 116

research due to the researcher's status as a trainee clinical psychologist (Alase.,

2017).

In IPA, reflexivity is the process through which the researcher reflects on their beliefs

and experiences and considers their impact on the analysis process. Clarity and

transparency regarding the researcher's relationship to the data are crucial in IPA

(Nizza et al., 2021). Engaging in personal reflexivity allowed the researcher to

acknowledge their closeness to the phenomenon of interest, values and beliefs and

how these may influence all stages of the research process.

IPA Process

Smith et al.’s (2021) guidance for conducting IPA was used to support the

analysis process. The researcher used a free coding approach to immerse

themselves in the participants' experiences and allow themselves to be

presumptive, biased, creative, and unsystematic in their annotations (Larkin &

Thompson., 2012). It allowed the researcher a space to reflect on their own

biases, e.g. free coding an experience as ‘harmful’ to find that participant later

described it as helpful.

Next, initial descriptive, linguistic and interpretive coding focused on

experience and meaning-making was completed on a new copy of the transcript

(Appendix I). Descriptive coding provided a summary of the content. Linguistic

coding highlighted repetition or phrasing considered interesting to the

researcher, e.g., repetitive use of the word detrimental was coded for P5.

Interpretive coding was generated by noting the researcher's questions about the

data; for example, ‘is the participant expressing frustration here? Was coded

tentatively as ‘Frustration?’

Well-being and Burnout in Psychologists 117

These three levels of coding were summarised in experiential

statements, which captured participants' emotional experience or

meaningmaking concerning their well-being experiences. Experiential

statements (ES) were printed and pinned onto a board in random order

(Appendix J). ES with similar themes were grouped in one area of the board and

labelled as emerging themes based on their connection, e.g., competing

demands, constant assessment, and others' expectations. Personal experiential

themes (PETs) were identified by grouping related emerging themes and

naming the PET based on the shared connection across emerging themes. This

process took place several times for each transcript. Each time a picture of the

PETs and included ES was taken as a record before re-arranging the ES to

consider alternative connections and groupings.

Once each transcript had been analysed, the overarching group

experiential themes (GETs) across transcripts were identified using the same

process as PETs (example provided in Appendix K). GETs were grouped based

on their similarities; several different groupings were recorded and discussed with

the researcher supervisors and colleagues in a University of Exeter IPA working

group. The final decision on GETs grouping was based on the researcher's

reflexive interpretation of the data.

Credibility

Data collection, analysis and interpretation were routinely discussed with

supervisors and an IPA working group at Exeter University to support credibility.

The analysis process and findings were presented at an academic conference at

the University of Exeter which offered an opportunity for critical review from

Well-being and Burnout in Psychologists 118

multiple perspectives. Transparency is imperative for the credibility of IPA

research (Levitt et al., 2018). Examples of individual and group analysis are

provided for transparency.

Reflexivity

Reflexivity is integral to the rigour and credibility of qualitative research

(Smith., 2011a). To support this research, I engaged in an IPA working group

(Smith et al., 2022), reflective journaling (Vicary et al., 2017), bracketing (Alase.,

2017), and consultation (Miller et al., 2018). Provided below is an overview of

how I used these methods to enhance reflexivity and rigour, along with examples

of reflexivity in action.

IPA Working Group

I attended an Exeter University IPA working group facilitated by an

experienced IPA researcher. A log of discussions from the IPA group can be

found in Appendix L. When coding data, feedback from the group highlighted

that the initial coding was heavily interpretive and missing descriptive content. In

one instance, when discussing well-being, the participant said, ‘…actually, there

is a lot of lip service to it’ which I initially coded as ‘Well-being Is insincere or

tokenistic’. By sharing the transcript with the IPA group, I realised that I was

focusing on a higher level of interpretation than was appropriate at this stage

and that the missing descriptive coding was a necessary part of the interpretive

process. As a result, the coding was changed to ‘well-being can feel like

lipservice with ‘insincere?’ as an additional code. This experience helped ensure

that the original data was identifiable in all interpretive comments throughout the

rest of the analysis process.

Well-being and Burnout in Psychologists 119

Reflective Journal

I kept a reflective journal where I explored my values, beliefs, feelings, and

experiences concerning the research process (Vicary et al., 2017)

(Appendix M). During an early interview, when describing their well-being experience, one

participant stopped describing their experience and said, ‘Well, you know how it is’. Using the

journal to capture post-interview reflections, I became aware that the participant had assumed

my experience as a trainee CP aligned with their own, inhibiting their sense-making description.

From the next interview, I was attentive to conversational cues, which suggested the participant

had assumed I had prior knowledge. I was careful to ask participants to expand on their

experiences by adding an additional prompt to my interview schedule (‘‘I’m really interested in

your experience. Please carry on if it feels comfortable.’). Doing this allowed me to feel I was

giving participants adequate space to tell their stories and minimise assumptions about my pre-

existing knowledge or training experience.

I also reflected on the interviews immediately after they took place. I

regularly met with a fellow IPA researcher to discuss our reflective journal entries.

Following my second interview, I noted, ‘[Participant] talked about how they were

making sense of some of their experiences for the first time in the interview.

Curious about why this might be?’ Together we wondered if this was the first

opportunity the participant had to reflect on this aspect of training. As a result of

this discussion, I noticed that within my sense-making experiences, I started to

feel as though CPs were placing themselves in a vulnerable position by taking

part and discussing their experiences for the first time. I also noticed increased

pressure to ensure the research did justice to participants' experiences.

Well-being and Burnout in Psychologists 120

Consultation

I sought consultation from a CP in a local NHS trust. When developing the

research questions, they highlighted the initial question, ‘What are clinical

psychologists’ experiences of well-being during training? was too broad and may

not capture participants' well-being learning experiences. Reflexive

conversations with the CP revealed this lack of specificity was rooted in my

knowledge of the DClinPsy training process and assumptions that others might

consider learning about well-being to be part of the DClinPsy experience. This

highlighted the importance of having reflexive spaces throughout the process to

attempt to re-position myself as a researcher rather than a trainee CP. For

example, when coding the data, I would ask myself, ‘Is that your sense as a

researcher or CP?’. Though I acknowledge that from an IPA perspective, I can

not separate myself as a researcher from my lived experience, this was a useful

way to balance informing and not biasing the analysis process.

Both research supervisors worked on DClinPsy courses which created

complexity regarding credibility due to the closeness of the research team to the

phenomenon of interest. This was evident in discussions about emerging themes

where it was sometimes difficult to consider the role of responsibility for well-

being from different perspectives. My research supervisors had alliances with

course staff whilst I attempted to balance my lived experience as a trainee with

my position as a researcher. There was also an imbalance of power between the

supervisee and supervisor, making it very difficult to hold these differing views

equally worthy of consideration. To contrast the internal perspectives held by the

research team, I consulted with an IPA-focused

Well-being and Burnout in Psychologists 121

Research Associate at an external university who had no affiliation with

DClinPsy training. The consultant’s unfamiliarity with the DClinPsy process was

helpful in re-positioning the discussion to more of an outsider position. In doing so,

I identified that the power imbalance between myself and my supervisor made me

feel I needed to prioritise my supervisor's views in the analysis and interpretation.

As a result, the views of participants were getting lost. Reflexive discussions with

an external critical perspective helped prioritise participants' voices. Reflexivity is

explored further in the reflexive statement (Appendix O).

Findings

This study examined CPs experience of learning about well-being during

training and how their learning about well-being impacted their post-qualification

experiences. The overarching GETs are represented in Figure 2. GETs relating

to participants' experiences during and after training highlight differences in the

challenges to well-being faced in the trainee period compared to

postqualification. For example, participants experienced fluctuating pressures

from competing academic, clinical and research demands. In contrast, once

qualified participants experienced pressure aligned more with increased

responsibility and specific service demands. The overarching GETs encompass

participants' lived experience of well-being pre and post-qualification. Though

they are not directly related to the research question, they have been included in

Figure 2, as they highlight the qualitative differences in experience during and

after training, which helps to understand how the learning during training was

not always helpful.

Well-being and Burnout in Psychologists 122

The main learning experiences were identified in four GETs (highlighted in

yellow in Figure 1). These were selected for discussion as they most directly

address the research question relating to CPs' learning experiences related to

well-being and post-qualification impact. How CPs learnt is encompassed in

theme 1: implicit messages about well-being. Theme 2: well-being is not

prioritised, and theme 3, connection maintains well-being, provides insight into

what was learned. Finally, theme 4: feeling inadequately prepared for

postqualification life, addresses the impact of learning. A breakdown of the

number of contributing participants per theme is provided in Appendix P.

Well-being and Burnout in Psychologists 124

Figure 1

An overview of the emerging GETS organised by career stage, themes most relevant to the research questions are highlighted

Well

being

throughout training

Sources of Pressure

Barriers to Accessing Help

Gratitude for training

place

Personal Characteristics

Connections Maintains Well

being

Validation through

shared experience

with

cohort

Containment and

guidance from

supervisors

Implicit and Explicit messages about well

being

Important Factors in

managing well

being

Feeling inadequately prepared for post

qualification

life

Unlearning

messages

from training

Reducing Working Hours

Hours

Sources of Pressure

Unsupported and unheard by course

Increased

responsibility

Service

Pressures

Expectations

from others

Lack of

support

Not

feeling

Valued

Well

being

support felt

tokenistic

Choice of Job Role

Setting Boundaries

Training Lacked helpful

learning opportunities

Well

being

Post

Qualification

During

Training

Up and Down

Gradual Decline

Competing Demands

Constant Assessment

Expectations from

others

Well

being is not important / prioritised

Expectations to prioritise

workload over work

life balance

Training Requirements more

important than wellbeing

Theme 1: Implicit Messages about Well-being

A key theme in participants' well-being-related learning experience brings

attention to how participants learned. It captures the significance that

participants placed, within their ideographic sense-making, on the unspoken

aspects of communication. Several participants, including P4 and P11 (shown

below), used the word ‘implicit’ in their sense-making accounts, whilst others,

such as P7 described ‘unspoken rules’ that existed in the communication

between themselves and others.

Participants seemed to experience and make sense of these

communications and learning interactions as insidious, captured by descriptions

of the learning as ‘powerful’ (P2) whilst also being ‘just really unhelpful’ (P9). At

some point in their interview transcripts, all participants who contributed to this

theme referred to an interaction with an individual as an interaction with ‘the

course’. This highlighted a sense of ‘othering’ in how participants made sense of

the relationship between trainees and course staff.

For some participants, these implicit messages communicated a belief

that participants should not ‘complain’ about their well-being. There was a

sense that participants felt an expectation from course staff to be grateful for

their place on training.

P:4 ‘…yeah I think there's lots that the course has going for it in terms of

the funding [ …], but I think it does perpetuate this “you should be

grateful to be here” mentality. I really felt that that was an implicit

message that you shouldn't complain too much 'cause we're doing you a

favour by letting you be here and funding this course for you.’

For some participants, this expectation or culture of gratitude seemed to

cause frustration and was experienced as invalidating or in conflict with their

lived experience of clinical training.

P:11 ‘…I felt there was an implicit kind of message if you have to get on

with it, don't complain too much, and you are fortunate to be here; you're

lucky to have your place on your course with all this funding. Just be

quiet, get on with it and don't cause too much trouble.’

This participants sense-making of expectation to be grateful appears to

allude to a sense that these interactions discouraged them from speaking out

about their well-being experiences. Another participant described how implicit

messages were received about the acceptability of discussing well-being during

training.

P3: ‘…I made a comment along the lines of “sometimes I find it really

hard to separate the stuff that's happening for me in the room and the

anxiety of being a new trainee”,… and I remember the person that was

leading the session being like “, yeah and that's why it's really important

that you have the space to think about that”, and then just moving very

quickly on with something else. And I remember thinking, okay, so the

message is we're not talking about that now that's too much deal with it,

and then there was no check-in after.’

Participants connected with this aspect of their experience by sharing

specific examples of times they received implicit messages, quoting language,

describing their emotional response to the experience, and offering more

generalised learning or ‘rules’ about well-being that they took from the

experience. Participants did not distinguish between the messages learned from

their academic versus their NHS experiences. Though this might reflect the

interconnected nature of the clinical and academic aspects of training, it may

also suggest a homogeneity in participants’ experience of well-being cultures

across the different organisational subcultures.

Theme 2: Well-being is Not a Priority

Most participants reported not feeling their well-being was a priority

during clinical training. This deprioritisation appeared to be held by others, and

participants learned through interpersonal verbal and behavioural interactions

on training. This theme captured two distinct learned beliefs or assumptions

about well-being as experienced by participants.

Training requirements are more important than your well-being.

Half of the participants interviewed felt that the words and behaviours of

others communicated that the requirements of the DClinPsy were more

important than their well-being.

P6: ‘…I think that message implies, you know, maybe in a very unspoken

way, kind of, yeah, look after yourself. But first and foremost, make sure

you do everything you need to do to finish the course and kind of

everything else should get kicked to the side as long as you do the

course.’

There was also a learned sense from participants that others considered

well-being to be a ‘luxury’ (P10) not a necessity.

P:4 ‘…I think that probably emphasized again that you're here to do a job

that's what we're interested in is getting you through this course, and if

we can do that with you as a relatively functioning human at the end of it,

then that's great, but that's not essential.’

This quote suggests that some experienced a sense from course staff

that there was a split between the needs of participants as employees and their

emotional and well-being needs. Ultimately, this left them feeling that, from the

course perspective, their emotional well-being was considered less important

than their work responsibilities.

Another way in which participants described the de-prioritisation of

wellbeing was through the learned belief that they should ‘just keep pushing’

through normal limits for well-being. This learning happened through means

including discussions with ‘the course’, older cohorts, and local supervisors.

P4: ‘…I wonder if a bit of that came from the cohorts that went before us

as well, not necessarily in a negative way that more in a this is shit, but

you need to keep going, keep pushing on and we will support you if you

can.’

In conversing with other training cohorts, there was a sense of

participants experiencing the lack of consideration for wellbeing as an

inevitability that they ‘others have done it before me, and hundreds will get

through it after me […]That’s just the way it is’ (P11).

Expectations to prioritise workload over work-life balance Over half

of the participants experienced learning that there was an expectation for

them to work substantial additional unpaid hours on top of their contracted

working hours. Many participants described learning that their employer, in

this case, the NHS, expected them to work additional hours to complete their

job demands.

P:7 ‘…we had a very long reading list after every lecture.[…] That in itself

sets an expectation as to what you think people are going to be able to

achieve or how much time you think they should be spending in work on

top of the 9-5 day. Because I suppose if your 9-5 day is attending that

lecture, when do they suggest that you complete that reading?’

Some participants felt that there was no way to complete the course

requirements without working over their contracted hours and described feeling

pressured to complete their work at any cost.

P6: ‘That if you want to pass, if you want to get everything done by the

deadlines, which you need to do on the course, you ultimately have to

work all hours under the sun a lot of the time…’

For many participants, these beliefs that others expected them to work

additional hours and that this was required to complete their professional

responsibilities were generalised into their post-qualification beliefs about their

well-being.

P:6 ‘I almost carried that over into qualified life. So then I would be so

used to just working all the time. But if you got to five o'clock and I still

had the stuff to do up, you know yeah, sure like, and then I would just be

carrying on,’

This seemed to demonstrate how learned working practices during training

‘just rolled over’ (P4) into post-qualification, almost becoming the participant's

default way of working. One participant, however, acknowledged the expectation

to work additional hours but identified this as unhelpful and spoke of their ability

to boundary their behaviour around working hours once qualified.

P:10 ‘…I think these bad patterns get ingrained during training… I think

it’s completely damaging to well-being. I see it play out in my friends and

even on placement, and since qualifying friends will work on the

weekend to catch up on work or their logging onto their emails, and I’m

like absolutely not; no way you don’t pay me to do that I’m not doing it.’

The experience of a lack of boundaried working hours and practices

during training appeared to facilitate a move towards an increased rigidity in

terms of setting boundaries and how they applied their job description in their

post-qualification practice. For this participant, there was almost an oppositional

response to their training experience.

Theme 3: Connection Maintains Well-being

A central theme in participants' learning experiences was the connection

with others and the meaning that they placed on this connection.

Validation through shared experience with the cohort

The majority of participants expressed that their fellow trainees were an

essential source of support that ‘kept them going’ (P7) through training. There

was a general sense that participants would have felt unable to manage the

training process without having a ‘cohort of support’ (P2). Having a group of

peers experiencing the same or similar challenges was validating for

participants and formed an essential aspect of supportive cohort relationships.

P8: ‘…I think some of the kind of the nice things that that I kind of learned

was actually about that sense of kind of peer camaraderie, sort of

validation. I don't think - there are lots of things that are problematic, I

guess, about my training experience, but the one thing that wasn't was

the people I was training with and having that was such a massive

support system to me at the time.

For some participants, there was meaningful learning around the

importance of shared experience and how this is related to an increased

understanding from others which participants valued.

P: 7: ‘…I certainly learned the value of peers, and I think that's still

something that I draw on now post-qualification. I had a really good

group of friends within my trainee cohort, and we're still good friends

now, and I think that really showed me the value of being able to have

peers who are in a similar situation if not the same situation as you and

they have that sense of understanding that maybe your family or friends

don't have.’

Participants experience of support from their cohort led to them feeling

understood and validated their experience of distress during training, leaving

them to make sense of these relationships as a helpful tool in managing

wellbeing.

Feeling supported by supervisors

Support from local clinical and internal course supervisors was also

considered important learning in relation to maintaining well-being during

training. Some participants found that feeling well-supported enabled them to

feel more able or motivated to prioritise their well-being.

P10: ‘…I think the driving force that powered me to [prioritise my

wellbeing] was that I had a really good personal tutor supervisor; he was

very supportive..’

For others, supervisors were important in keeping them ‘focused on

getting through it and getting out the other side’ (P11)

P2: ‘…Luckily had a really, really good supervisor who just kept me on

the straight and narrow with it. That was really, really important for my

well-being.’

Others made sense of their learning experience by understanding

supportive relationships as being helpful in ‘navigating’ difficulties with

wellbeing.

P:4 ‘…My local supervisors were always very very good, one of my

supervisors was also my line manager through a lot of training as she was

always very supportive, and I could go to her with things. And she helped me

navigate some of those difficulties.’

When discussing supervision, some emphasis was placed on the

importance of relationships with local supervisors; participants' descriptions of

their experiences suggested that there was something meaningful about

supportive relationships with people who were slightly removed from the training

course itself.

Theme 4: Feeling Inadequately Prepared for Post-qualification Life

Regarding the impact of their learning experiences post-qualification, over

three-quarters of the participants reported that their experiences had left them

feeling unprepared to manage their well-being once they qualified.

Missed opportunities for learning about positive well-being management

Seven of the participants felt that clinical training did not prepare them for

the challenges to well-being they would face as qualified CPs. Participants

expressed a sense of missing out on opportunities for well-being-related

learning, which would have helped them better manage the post-qualification

period. Participants highlighted that they experienced training as focused on

passing the course rather than on ‘equipping us for what being a psychologist is

actually like (P8)’.

P: 7: ‘…my experiences of being on the course were that it was very

focused on meeting the competencies that you needed to meet and

completing the assignments that you needed to complete; I don't think

we were taught a lot about how to manage your own well-being and how

we can utilise self-care and how important advice all that is post

qualification.’

Two participants talked explicitly about the specific role of CPs in the

NHS workforce. They felt that training lacked opportunities to learn what is

expected of them within this role and how to be assertive when working in

complex NHS systems. One participant reflected on their experience of burnout

following training. One way they make sense of their experience is due to

missed opportunities to fully learn about the expectations of CPs in the NHS

workforce and how to advocate for themselves professionally.

P4: ‘…I think another thing that contributed to the burnout, which the

course could have prepared me for, but they didn't, was just knowing what the

role should look like. I have the impression that if I was going to my managers

and saying this is too much, I can't do this then that's me saying I can't do my

job because they wouldn't give me these things to do unless they thought that

was part of my job as a psychologist… The NHS is awkward and clunky, and it

doesn't always work, and I think you need to be able to point that out and stand

up for yourself within that, and that's really important for your well-being, and I

don't think the course really prepared, us for that at all.’

For many participants, including P4, there was a sense of feeling let

down and increased vulnerability in the newly qualified stage due to the missed

training opportunities and having to rely on others to outline what is and is not

expected of them in the workplace.

Counterproductive Learning Experiences

When detailing their ideographic learning experiences relating to

wellbeing during clinical training, several participants described holding onto

learned behaviours in their working practice that were unhelpful

postqualification.

P6: ‘…Yeah, I’m having to unpick a lot of things I learned about working

over, prioritising my own well-being, not wanting to disclose etc.’

Participants talked about different ways in which their learning had been

counterproductive, as described by P6 above; some were able to identify

specific pieces of learning which underpinned these working practices.

P8: ‘…It’s like training sets you up to ignore your own red flags that

things are too much because there’s just so much to do, and rather than

preparing you for post-qualified life, it becomes actively unhelpful.’

Here, P8 describes how they learned to ignore or dismiss signs that their

well-being was deteriorating because of a sense that their work demands took

priority. For many, a sense of frustration was caused by a felt experience that

they had to unlearn these working behaviours and beliefs instilled during clinical

training. Participants described this unlearning process as needing to take place

to better manage their well-being post-qualification.

For others, their learned response was not just about unpicking aspects

of their learning but more of an oppositional behavioural response to their

experience.

P: 10 ‘…I think, if anything, my experiences of well-being during training

has given me something- or have left me wanting to do the opposite of

what happened in training. So now, if there’s any suggestion about really

doing some work outside of hours, I’m like, no, absolutely not.’

Discussion

Maintaining well-being is important in preventing burnout and

occupational distress in CPs (Rupert & Dorocaik., 2019); however, historically,

CPs have struggled to acknowledge this importance (Wise et al., 2012). This

study explored CPs' experiences of learning about well-being through training

and the impact of this learning post-qualification. To the researcher's

knowledge, this study is the first to present findings related to this aspect of CPs

well-being experiences.

Using IPA, four group experiential themes were identified: implicit

messages about well-being, well-being is not a priority, connection maintains

well-being and feeling inadequately prepared for post-qualification life. The first

theme refers to how CPs learned. The following two focused on what CPs

learned. Whilst the remaining theme captures the experienced impact of CPs'

learning. A difference in the experience of well-being stressors during and after

training were also observed. Themes are discussed alongside relevant theory

and research.

How CPs Learn About Well-being

Implicit Messages about Well-being

Participants in this study described highly influential learning experiences

relating to well-being through the receipt of implicit messages from the course

staff. Often, these messages demonstrated beliefs held and communicated by

‘the course’ (a term used by all participants to refer to course staff as a

collective) about how CPs were expected to view their well-being and behave in

relation to their well-being management. Participants described these

messages as unhelpful, negatively impacting their lived experience of wellbeing

and what they learned about managing well-being. Underlying beliefs and

assumptions are indicators of OC which can often be unspoken and even

unconsciously held beliefs that individuals are unaware that they are holding

and communicating to others (McSherry & Pearce., 2018). The participants'

experiences in this study may represent deep and underlying manifestations of

the OC relating to well-being across DClinPsy training courses (Mannion &

Davies., 2018). Little is known about how CPs learn about well-being during

training; however, research acknowledges that clinical training programmes are

ineffective at equipping CPs to manage their well-being (Lambert & Simon,

2008). The findings suggest that a significant aspect of CPs' learning about

well-being occurs through communicating underlying cultural beliefs and

assumptions.

Participants' descriptions of their learning experiences support claims

that NHS working practices are heavily influenced by unspoken aspects of

organisational culture (OC) (Dixon-Woods et al., 2013); however, the reference

to course staff indicates that implicit messages are also part of the academic

culture which provides an early insight into the academic culture experiences by

trainee CPs. Consequently, the dual identity held by CPs as students and

practitioners may make them vulnerable to multiple OCs in their experience of

learning about well-being. This aspect of trainee CPs experience is yet to be

explored, but the literature would benefit from a deeper understanding of the

impact of holding dual status during clinical training. In the meantime, these

findings suggest that course providers should carefully consider the different

organisational influences when developing and delivering course competencies

relating to well-being.

For CPs in this study, learning about well-being was a complex

embodied experience, and relying solely on psychological discourse (such as

lectures) to address well-being during training may be insufficient to meet the

needs of CPs (Stolz., 2014). Embodied learning theories acknowledge the role

of the body and emotions in the learning process (Kontra et al., 2012) and are

regularly incorporated into primary, secondary and higher education

(Rodríguez-Jiménez & García-Merino., 2017; Schmidt et al., 2019). CPs often

spoke of their emotional responses to their well-being learning experiences,

thus, highlighting the importance of emotionally embodied learning opportunities

for trainee CPs. Embodied learning principles may be beneficial in supporting

and improving the well-being-related learning experiences of CPs during clinical

training.

Clinical psychology training is among the UK's most sought-after

postgraduate psychology programmes (Callahan et al., 2018). There are large

numbers of applicants for comparatively few funded places (Scior et al., 2014;

Demetri et al., 2023). As a result, there is a culture of intense competition

among prospective applicants (Smith., 2014). Through interactions with course

staff, participants experienced an expectation from others to be grateful for their

training place, which was dismissing of participants' lived experience of training.

The experiences discouraged participants from expressing distress relating to

course challenges. The application process has been shown to take an

emotional toll on aspiring CPs (Demetri et al., 2023); however, the research has

not explored the longer-term impact of the application process on CPs. The

findings of this study suggest that experiencing the highly competitive

application process may contribute to a culture of expected gratitude, which

may dismiss the well-being experiences and needs of trainee CPs.

What CPs Learn About Well-being

Well-being is Not a Priority

The importance of culture was apparent in how CPs learned about

wellbeing and what they learned. Like their medical colleagues (Rich et al.,

2016), CPs described learning that there was an expectation to subjugate their

wellbeing needs for their clinical training requirements. Traditionally, the JDRM

has relied on separate models and theories to understand the aspects of OC in

the experience of well-being (Lopez-Martin & Topa., 2019), such as subjugation,

as they are neither a demand nor a resource (Taris & Schaufeli., 2018). Often

the focus in supporting CPs to manage their well-being is to develop personal

resources (Pakenham & Stafford-Brown., 2012; Stafford-Brown & Pakenham.,

2012). This is evidenced in the BPS core competencies for psychologists, which

focus on developing strategies to '''handle' the emotional impact of their work

and the ability to monitor their fitness to practice (BPS., 2019, P.19). The

researchers argue that the demands and resources experienced by CPs are

rooted in the OC of their workplace (Dextras-Gauthier et al., 2012). By focusing

only on demands and resources, course providers risk over-attributing wellbeing

management to the individual and not acknowledging the wider environmental

impact (Slemp et al., 2015). Expanding the JDMR to include OC theories, as

recommended by Lopez-Martin & Topa (2019) could help to contextualise the

experiences of CPs and provide a greater understanding of the impact of NHS

working cultures. It also identifies OG as an area to target when developing

prevention and intervention strategies for supporting CPs wellbeing.

CPs in this study experienced expectations to work additional unpaid

hours, which is commonplace for NHS workers (Kim et al., 2018; Lawn et al.,

2020). CPs learned that the requirements of the training were more important

than their own well-being, which led to CPs subjugating their own needs. Much

like the wider NHS OC, this research provides evidence for an ongoing culture

of subjugation which is embedded during CPs clinical training.

Working additional hours can be a significant risk factor in developing

burnout (Lim et al., 2020). However, an interesting distinction exists between

the employer expectations of trainees and qualified CPs. It is generally

accepted that healthcare staff should not work outside their contracted hours

(Warner & Zaranko., 2020); however, this is not necessarily the case for

trainees. Trainee CPs are paid NHS employees who also complete a funded

academic qualification, which they can use to increase their professional

earnings, status, and responsibilities for the remainder of their careers (Clearing

House., 2023). Achieving a doctoral-level qualification is a demanding and

timeintensive process (Utami., 2019). Doctoral students across various

disciplines would be expected to work long hours to complete their studies.

Many students work full or part-time alongside their education to fund their

studies (Rowe., 2021). Therefore, the expectations on trainee CPs are not

unlike those placed on other doctoral or PhD students. Given the personal

benefits and the dual role of doctoral students, the expectation of completing

some of the academic components outside of work hours may be a reasonable

and realistic expectation for trainee CPs. From reviewing the application

information, however (Clearing House., 2013) the academic expectations

around working hours may not be emphasised clearly enough to prospective

applicants. Our findings highlighted that greater clarity and transparency from

clinical training courses around the dual role, and expectation of trainee CPs,

could be beneficial in managing the expectations of trainee CPs. Well-being

may be supported by setting clear expectations from the point of application

through to training itself.

Connection Maintains Well-being

Peer relationships have a positive impact on the well-being of healthcare

workers. Research has shown positive peer relationships can provide validation

(Viswanathan et al., 2020), and enhance coping strategies (Leng et al., 2021).

Participants in this study highlighted their supervisors and trainee colleagues as

being vital in managing their well-being throughout training. The shared

experience within peer relationships was particularly helpful as it provided

validation and an increased understanding of the nuances of training that family

and friends may not understand. Among healthcare workers, shared

experiences have been shown to improve well-being and decrease

occupational burnout (Kelsey et al., 2023). As such, this is a really important

finding supporting the potential benefit of encouraging peer relationships within

clinical training. As such, CPs should be supported and encouraged to form

meaningful relationships with their colleagues throughout; this could be

achieved through team building, reflective practice, and using compassionate

models to underpin team ethos.

The Impact of CPs Learning Post-Qualification

Feeling Unprepared for Post-qualification Life

Ultimately, for 10 participants, their training experiences left them feeling

unprepared to manage the challenges they faced post-qualification. Lambert & '

'Simon's (2008) claimed that clinical training courses fail to prepare CPs to

manage their well-being post-qualification, but they do not provide any insight

into why this might be. The participants' experiences in this study suggest that

CPs may feel unprepared for two reasons: missed opportunities for learning and

counterproductive learning experiences.

A substantial body of research details the complexity of NHS systems,

including its processes, pathways, and constantly changing economic and

legislative landscape (McKee., 2021). Participants described the challenges of

working in complex NHS systems and the lack of opportunities to develop

essential skills in assertiveness and boundary setting to help them navigate

this. The participants' commentary on their experiences of feeling unprepared

are concerning, given that the theoretical foundation of the competency-based

learning ethos, on which doctorate programmes are built, is to prepare trainees

more efficiently for clinical practice (Kenkel & Peterson., 2010). It highlights the

importance of adequate consideration and pre-qualification preparation for the

transition from trainee to CP and the associated challenges of the NHS context

to enable trainees to feel adequately prepared to manage their well-being.

Participants also reported that much of their learning experiences around well-

being during training were not helpful to their well-being post-qualification. The

difference in experienced job demands for trainee and qualified CPs indicates

that learning about well-being as a trainee might not be transferable to

managing the different pressures and expectations faced post-qualification.

According to Melesis's Transitionary Model as applied to student nurses, upon

qualification, there is a transition from the role of student to the qualified

practitioner (Melesis., 2010). Throughout this transition, the practitioners, in this

case, CPs, must learn to adjust to the new expectations and demands of their

qualified role (Wildermuth et al., 2020). It is common for practitioners who

transition from higher-level academic qualifications to feel overwhelmed by their

new job demands and feel unprepared (Unruh and Nooney., 2011). Additionally,

the change in responsibility may leave CPs feeling as though the well-being

strategies they learned during training do not meet their post-transition needs.

The level of social support, and guidance available from staff members during

the transitionary period, can significantly improve the success of the transition

period for student nurses (Meleis., 2010) and could be a helpful target for

interventions to support CPs’ well-being during the transition to post-

qualification.

One counterproductive learning experience described by participants

was learning to ‘to ignore your own red flags’ (P8), and they made sense of this

as being because there was ‘so much to do’(P8). By being encouraged to place

the job demands ahead of their well-being, participants learned to ignore signs

that their mental health and well-being were deteriorating. Once again, this

highlights that not only is the longstanding NHS culture of subjugation

(Mackenzie., 1995; McCarthy et al., 2020) a potential aspect of OC within the

DclinPsy training, but the findings provide an insight into how this is learned

during training, and the subsequent impact on well-being management. This

learned behaviour around ignoring signs of declining well-being may have

serious implications for CPs' well-being post-qualification and warrants further

investigation.

Ultimately, the findings of this study suggest that OC may negatively

impact CPs well-being-related learning experiences during training. Supportive

supervisory and peer relationships may play an important role in maintaining

CPs well-being pre- and post-qualification; however, the post-qualification

transitionary period for CPs can present challenges to well-being. The differing

experiences and expectations of trainees and qualified CPs may contribute to

the difficulties experienced during the training and transition period.

Implications and Recommendations for Clinical Psychology

Well-being beliefs and assumptions held by the DClinPsy community

may be shared, learned and maintained through implicit communication with

other community members, including course staff, different training cohorts, and

NHS placement providers. Findings suggest that training course providers may

benefit from focusing less on providing formal well-being learning opportunities,

such as lectures and workshops (Choi and Jacobs, 2011), and more on

identifying embodied experiential learning relating to well-being opportunities.

By examining (Panescu., 2021) underlying beliefs and assumptions about

wellbeing (Schein., 1998;) held by the different members of the DClinPsy

training community and how these are communicated to trainees throughout

their training DClinPsy courses may be able to improve CP's positive well-being

learning experiences.

Additionally, the interpretation of participants' lived experiences suggests

an expectation to subjugate one's well-being needs in place of role or course

demands is being communicated to CPs during training. This highlights an

identifiable behavioural feature of OC. Courses may benefit from exploring the

underlying beliefs relating to subjugation and how this is being communicated

through espoused values (Macfarlane et al., 2013), such as written

communication to CPs.

By engaging in the suggested explorations of OC, course providers may

be able to develop a greater sense of the well-being culture within the DClinPsy

and how this contributes to CPs' individual learning experiences as well as the

socially cohesive behaviour concerning well-being within clinical training and

post-qualified CPs (Macintosh & Doherty., 2008). Each of the 30 training

course providers will likely have distinct well-being cultures shaped by the host

university, local geographical and cultural influences and senior management

team. As such, each DclinPsy course should aim to individually explore the

beliefs and assumptions about well-being and how these manifest in their

DclinPsy training programme to help identify opportunities for meaningful

change (Mannion & Davies., 2018). Courses could do this by assigning

independent clinicians to complete observations and evaluations of all aspects

of the course, including the perspectives of course staff, clinical supervisors

and trainees, and providing a written report. This could be shared with existing

and previous DClinPsy community members for comment and used to generate

target areas for development. A brief literature review found no evidence of

explorations such as this in any other NHS training courses; as such, there is an

opportunity for DclinPsy courses to champion this type of exploration of OC and

well-being in professional training courses.

To draw upon the potential benefits of connection with others, training

providers and local NHS trusts should consider fostering supportive

relationships within teams, services and organisations. There are several ways

in which teams may choose to do this; Schwartz Rounds provide structures

forums for staff across all levels of an organisation to connect over shared

experiences regarding the emotional impact of their work (Flanegan et al.,

2020), which peer support groups specifically for trainee CPs and newly

qualifies CPs may provide safe spaces free of fear of assessment or appraisal

from senior staff (Ooi., 2019). DclinPsy courses may benefit from encouraging

the development of a clan-based culture where all members of the DclinPsy

community are encouraged to value and foster kinship, mentoring, teamwork

and collaboration (Cameron et al., 2022).

This research suggests room for improvement in the experience of

learning about well-being for CPs. To maximise learning opportunities during

training, the researchers propose adding a tenth core competency to the BPS

framework (BPS., 2019), called ‘Personal and Professional Well-being’. This

competency would focus on developing personal resources, awareness of

organisational culture theories and research, ability to observe and critically

assess organisational cultures, reflection on their well-being learning

experiences, fostering a connection with others, and preparing for the transition

to post-qualification. Incorporating this into the core competencies framework

means that course providers would be audited and regulated on the

effectiveness of this aspect of their course provision as part of the

reaccreditation process.

Limitations

Interpretive Phenomenological Analysis

The researcher's position as a trainee CP will have shaped the design,

data collection, development, and interpretation of the findings (Smith et al.,

2022). As detailed above and in the supporting appendices, the researcher took

several steps to minimise the risk of bias and ensure that the researcher

remained committed to an iterative approach to GET development, being led by

the data at all times. The researcher has endeavoured to provide a high level of

transparency concerning reflexivity, rigour and credibility, enabling the reader to

determine the study's quality and credibility. Though this is a fundamental

aspect of IPA, the researcher acknowledges that their relationship to the

phenomenon of interest increases the risk of researcher bias in the analysis

and interpretation.

Population and Sample

The population sample was small, and there was a lack of diversity,

particularly regarding gender and race. A robust justification exists for a smaller

sample within the IPA methodology (Smith et al., 2021). The aim here was to

explore the lived experiences of a small homogenous group and generate

findings that, when applied tentatively, could be meaningful to a larger,

appropriately homogenous group. The lack of diversity, however, is important as

it reflects the lack of diversity in the wider clinical psychology field (Callahan et

al., 2018). Future research would benefit from greater gender diversity, whilst

similar explorations could focus specifically on the experiences of people from

UK minority groups, typically underrepresented in clinical psychology (Dimmick

& Callahan., 2022).

Due to the volunteer sample, there is likely to be a sampling bias here,

as participants likely chose to participate because they had an invested interest

in well-being due to their lived experiences (Tiit et al., 2021). This is likely to

impact the sample's representativeness.

Contextual Demographic Information

Researchers did not ask participants to disclose which DClinPsy course

they completed. As a result, findings could not be discussed in the context of

the individual’s training course. Opportunities for considering divergence and

convergence of themes, such as experiences of connection for those with larger

versus smaller cohorts, were missed. Given how many clinical psychologists go

on to work on or in conjunction with training providers, the decision not to record

training institutions felt more aligned with the principles of IPA in enabling

participants to share their lived experiences and meaning-making organically.

Expansion of DClinPsy Training

In 2021, Higher Education England to increase UK training places for

CPs by 25% (Bawa et al., 2021). As a result, course providers have been

tasked with supporting more trainees than ever without significant increases in

resources or NHS capacity to provide placements. Unfortunately, as these

changes are relatively recent, there is a lack of research or anecdotal accounts

that explore the impact of the expansion of courses on the experience of

trainees. As this research is the first to explore CP’s well-being learning

experiences during training, researchers cannot comment on the impact of the

expansion of DClinPsy courses on the well-being learning experiences captured

in this study.

Further Research

Findings indicate that a more focused exploration of the role of implicit

communication in well-being learning across DclinPsy courses may be

beneficial. Researchers may wish to consider discourse analysis which can

facilitate an exploration of how language is used in conversations relating to

well-being and support a larger sample size (Paltridge., 2021). Researchers

should consider multiple perspectives in their exploration of DClinPsy culture

and well-being. Thus, qualitative explorations from the perspective of Clinical

Psychology doctorate staff, who hold a different hierarchical position to trainees

(Ovseiko & Buchan., 2012) may also provide insight into the learning culture

relating to well-being.

Participants experienced feeling unprepared for post-qualification. The

field may benefit from a large-scale quantitative study exploring clinical

psychologists' transition from pre to post-qualification. Researchers may wish to

use a transition theory adapted for healthcare training, such as the one posed

by Meleis (2010), as a theoretical basis for the enquiry. As this would be the first

study of its kind, a broader exploration of the transition process, with some

space for more specific enquiry related to preparedness, may benefit. This may

provide a greater understanding of CP’s transition into post-qualification, inform

the clinical psychology training process and provide guidance for supporting the

transition, as has been demonstrated by research relating to nurses (Kumaran

& Carney., 2014).

Conclusion

This IPA study aimed to explore CPs well-being related to learning

experiences during clinical training and the impact of this post-qualification. This

study found that much of CPs learning occurs through implicit communication of

underlying beliefs and assumptions about well-being between CPs and

DClinPsy course staff. Participants' experiences highlighted a well-being culture

in which individuals learned that well-being is considered to be less important

than job demands and where many CPs feel pressure to work unpaid hours.

Participants found validation and support in their relationships with peers and

supervisors which appeared to support individual experience of well-being. The

well-being learning experiences during training left many participants feeling

unprepared for the challenges of post-qualification work and in a position where

they felt less equipped or able to notice signs that their well-being needed

attending to.

The analysis demonstrates that an increased focus on understanding

and exploring the underlying beliefs within and across DclinPsy course

providers may be beneficial in understanding how to make meaningful changes

in the well-being and learning experiences of CPs. By including well-being as a

core competency DclinPsy courses may be able to provide a structure within

which they can better equip CPs for long-term careers in the NHS. Individual

course audits exploring different manifestations of well-being culture across the

DClinPsy provision may help to generate evidence to support culture change.

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