This systematic review protocol has been reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2015 checklist (PRISMA-P)  (Additional File 1). Due to the diverse types of qualitative and quantitative studies and the heterogeneity of the sample that will be included in the review, meta-analysis will not be possible. The results will be synthesised thematically. The protocol was registered in advance with the International Prospective Register of Systematic Reviews (PROSPERO): CRD42020203195.
The overarching research question for this systematic review is:
What impacts burnout and psychological wellbeing in Australian postgraduate medical trainees?
This systematic review will aim to include empirical peer-reviewed studies published in academic journals. First, the lead author (BB) will undertake a structured search in the following databases:
These databases have been chosen as they provide access to current, scholarly peer-reviewed journals in the fields of health, psychology and education. Search terms will be set up using the PIO (Population, Interest, Outcome) framework. Initial search terms are outlined in Additional File 2.
The initial search will be re-run immediately before analysis commences and any additional studies retrieved for inclusion. The database searches will be restricted to include articles published from 1 January 2000 onwards. Only articles available in English will be included. A search of the reference lists of included studies will also be conducted to identify additional articles for inclusion. A Google search will be run to identify any relevant grey literature for inclusion.
Inclusion and exclusion criteria
For the purposes of this review, postgraduate medical trainees will be defined as graduates with a medical degree who are in working in pre-vocational (intern, resident) or vocational (registrar) positions in the Australian healthcare system. Studies focused on medical students, consultants and senior doctors will be excluded, including those where results for postgraduate trainees are not reported separately from another population. Studies investigating Australian and New Zealand trainees together will be included, due to the similarity of training programs and the trans-Tasman governance of many medical colleges. Due to the scarcity of literature available, no limits will be applied in terms of age, gender, ethnicity or specialty training program.
For this review, the exposures of interest are defined as any factor of the work environment that demonstrates an association with, or an impact on, an aspect of psychological wellbeing. Examples of factors may include, but are not limited to, assessments and examination, working hours, support networks, experiences of discrimination or harassment, work-life balance and exposure to death and injury. Associations may be positive or negative.
The primary outcomes for this review will be any measure of one or more aspects of psychological wellbeing in Australian postgraduate medical trainees. Aspects of psychological wellbeing include, but are not limited to, burnout, mental health (including depression and anxiety), quality of life, and stress. Outcome data may have been collected by any qualitative or quantitative data collection method, or a combination thereof. Studies that focus solely on physical wellbeing rather than psychological wellbeing will be excluded.
Types of studies
This review will include published empirical peer-reviewed studies. All quantitative, qualitative and mixed-methods study types will be considered eligible for inclusion. Review papers, study protocols, commentaries, opinion pieces, letters to the editor, magazine articles and discussion papers will be excluded. Grey literature will be eligible for inclusion. Abstracts will not be included, but efforts will be made to locate an associated full-text publication. In order to include the most up-to-date literature, the search will be limited to articles published from 1 January 2000 onwards.
Search results will be downloaded to Microsoft Excel for review. Duplicates will be manually removed. Several steps will be undertaken to ensure rigour. Firstly, two screening processes will take place. In the first, titles and abstracts of each study will be downloaded and assessed by a minimum of two reviewers against the inclusion and exclusion criteria, and any studies not meeting the inclusion criteria will be excluded. Any disagreements in relation to inclusion or exclusion of studies will be discussed between the reviewers and agreed by consensus. If consensus cannot be reached, a third reviewer will be invited.
In the second screening, the full-text versions of the remaining articles will be independently reviewed by at least two reviewers. Disagreements will be discussed amongst the reviewers and agreed by consensus. If consensus cannot be reached, a third reviewer will be invited. Reasons for exclusion will be documented at each stage. If there is insufficient information to determine eligibility, the authors of the study will be contacted for further clarification. If further information is not available, the study will be excluded.
A detailed PRISMA flowchart of the selection process will be included in the final review.
Data extraction will be conducted for all eligible articles by a member of the research team, based on a modified version of the standardised data extraction form developed by Hall et al. . Extracted information will include the following: title, author, publication date, aims, study type, data collection tools, population, inclusion and exclusion criteria, response rate, recruitment method, limitations, statistical analysis, results and conclusions. Data extraction for all articles will be reviewed by a second author to ensure accuracy and reliability. It is expected that the data extraction will be an iterative process whereby the data extraction template may be modified as the process unfolds.
Confidence in cumulative evidence
Confidence in the findings of this review will be assessed using the Confidence in the Evidence from Reviews of Qualitative research (CERQual) approach . This will provide an assessment of the extent to which the findings are a reasonable representation of the phenomenon of interest (in this case, factors that impact burnout and psychological wellbeing in Australian postgraduate medical trainees). In essence, it provides an evaluation of the level of confidence that can be placed in the findings of this review.
The evaluation will provide an assessment of the following:
Methodological limitations: An evaluation of any problems in the design or conduct of the primary studies, guided by the quality assessment process described below;
Relevance: An assessment of the extent to which the primary studies are applicable to the context and aims of the review;
Coherence: An assessment of the extent to which the tendencies, patterns and relationships identified in the findings are grounded in data from the primary studies;
Adequacy of data: An overall assessment of the evidence supporting the review finding.
Each article will be assessed for quality and potential bias using the critical appraisal tools available from the Joanna Briggs Institute . These checklists use a three-option grading system of: include, exclude and seek further information based on desirable and undesirable effects, quality of evidence, values and preferences and costs . This suite was chosen as it contains 13 checklists for different study types, thereby providing a consistent assessment tool across all study types. For qualitative research in particular, the JBI tool scores higher for dependability and credibility compared to other similar tools . The most appropriate tool will be selected for each study type. Quality assessment will be conducted by two reviewers and disagreements resolved by discussion and consensus.
Analysis and reporting
Data will be analysed using a convergent qualitative synthesis process . Study results (quantitative, qualitative and mixed methods) will be transformed into qualitative findings such as themes, concepts and patterns . The thematic analysis process will be undertaken using a hybrid deductive-inductive approach, where data is initially assigned to predefined themes (deductive) and themes are revised or created based on data (inductive; ). Rigour in the transformation and analysis process will be achieved by discussion and consensus between three authors, with the fourth author providing arbitration for any disagreements . Narrative synthesis will then be used to relate these findings to the research question. An appraisal of the quality of the included studies will be provided based on the quality assessment process. Gaps in the literature and areas for future research will be identified.