Recommendations for improving the working conditions and cultures of distressed junior doctors, based on a qualitative study and stakeholder perspectives.

BACKGROUND: Doctors, including junior doctors, are vulnerable to greater levels of distress and mental health difficulties than the public. This is exacerbated by their working conditions and cultures. While this vulnerability has been known for many years, little action has been taken to protect and support junior doctors working in the NHS. As such, we present a series of recommendations from the perspective of junior doctors and other relevant stakeholders, designed to improve junior doctors' working conditions and, thus, their mental health. METHODS: We interviewed 36 junior doctors, asking them for recommendations for improving their working conditions and culture. Additionally, we held an online stakeholder meeting with a variety of healthcare professionals (including junior doctors), undergraduate medical school leads, postgraduate speciality school leads and NHS policymakers where we asked what could be done to improve junior doctors' working conditions. We combined interview data with notes from the stakeholder discussions to produce this set of recommendations. RESULTS: Junior doctor participants and stakeholders made organisational and interpersonal recommendations. Organisational recommendations include the need for more environmental, staff and educational resources as well as changes to rotas. Interpersonal recommendations include changes to communication and recommendations for better support and teamwork. CONCLUSION: We suggest that NHS policymakers, employers and managers consider and hopefully implement the recommendations set out by the study participants and stakeholders as reported in this paper and that the gold standards of practice which are reported here (such as examples of positive learning environments and supportive supervision) are showcased so that others can learn from them.

Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK.

BACKGROUND: Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes. METHODS: We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration. RESULTS: Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours. CONCLUSIONS: There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.

Community midwives views of postnatal care in the UK; A descriptive qualitative study.

OBJECTIVE: To explore views and experiences of community midwives delivering postnatal care. DESIGN: A descriptive qualitative study design undertaking focus groups with community midwives and community midwifery team leaders. SETTING: All focus groups were carried out in community midwifery care settings, across four hospitals in two NHS organisations, April to June 2018 in the West Midlands, UK. PARTICIPANTS: 47 midwives: 34 community midwives and 13 community midwifery team leaders took part in 7 focus groups. FINDINGS: Inductive framework analysis of data led to the development of themes and sub-themes relating to factors influencing discharge from hospital, strategies to address increases in discharge and the broader challenges to providing care. Conditions on the postnatal ward and women's experiences of care in the hospital were factors influencing timing of discharge from hospital that resulted in community midwives managing women and babies with more complex needs. In order to manage increased workloads, there was growing but varied use of flexible approaches to providing care such as telephone consultations, postnatal clinics, and maternity support workers. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: In a context of short postnatal hospital stays, community midwives appear to be responding to women's needs and service pressures in the postnatal period. Wider implementation of specific strategies to organise and deliver support to women and babies may further improve care and outcomes.

Sources of work-related psychological distress experienced by UK-wide foundation and junior doctors: a qualitative study.

OBJECTIVES: This paper reports findings exploring work cultures, contexts and conditions associated with psychological distress in foundation and junior doctors. DESIGN: Qualitative study using in-depth interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING: NHS in England. PARTICIPANTS: A purposive sample of 16 female and five male junior doctor junior doctor participants who self-identified as having stress, distress, anxiety, depression and suicidal thoughts, or having attempted to kill themselves. RESULTS: Analysis reported four key themes: (1) workload and working conditions; (2) toxic work cultures-including abuse and bullying, sexism and racism, culture of blaming and shaming; (3) lack of support; (4) stigma and a perceived need to appear invulnerable. CONCLUSION: This study highlights the need for future solutions and interventions targeted at improving work cultures and conditions. There needs to be greater recognition of the components and cumulative effects of potentially toxic workplaces and stressors intrinsic to the work of junior doctors, such as the stress of managing high workloads and lack of access to clinical and emotional support. A cultural shift is needed within medicine to more supportive and compassionate leadership and work environments, and a zero-tolerance approach to bullying, harassment and discrimination.

Protective factors and sources of support in the workplace as experienced by UK foundation and junior doctors: a qualitative study.

OBJECTIVES: This paper reports findings identifying foundation and junior doctors' experiences of occupational and psychological protective factors in the workplace and sources of effective support. DESIGN: Interpretative, inductive, qualitative study involving in-depth interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING: National Health Service in the UK. PARTICIPANTS: Participants were recruited from junior doctors through social media (eg, the British Medical Association (BMA) junior doctors' Facebook group, Twitter and the mental health research charity websites). A purposive sample of 16 females and 5 males, ethnically diverse, from a range of specialities, across the UK. Junior doctor participants self-identified as having stress, distress, anxiety, depression and suicidal thoughts or having attempted to kill themselves. RESULTS: Analysis identified three main themes, with corresponding subthemes relating to protective work factors and facilitators of support: (1) support from work colleagues - help with managing workloads and emotional support; (2) supportive leadership strategies, including feeling valued and accepted, trust and communication, supportive learning environments, challenging stigma and normalising vulnerability; and (3) access to professional support - counselling, cognitive-behavioural therapy and medication through general practitioners, specialist support services for doctors and private therapy. CONCLUSIONS: Findings show that supportive leadership, effective management practices, peer support and access to appropriate professional support can help mitigate the negative impact of working conditions and cultures experienced by junior doctors. Feeling connected, supported and valued by colleagues and consultants acts as an important buffer against emotional distress despite working under challenging working conditions.

Patients' and health professionals' attitudes and perceptions towards the initiation of preventive drugs for primary prevention of cardiovascular disease: a systematic review of qualitative studies.

BACKGROUND: Statins and antihypertensive agents are recommended for primary prevention of cardiovascular disease (CVD), but they are not always prescribed to eligible patients. DESIGN & SETTING: A systematic review of qualitative studies. AIM: To explore health professionals' and patients' attitudes towards cardiovascular preventive drugs. METHOD: MEDLINE, Embase, PsychINFO, CINAHL, ASSIA, HMIC, Conference Proceedings Citation Index, and Open Grey were searched for studies of qualitative design without restrictions on date or language. Two reviewers performed study selection, data extraction, quality assessment, and thematic synthesis. RESULTS: In total, 2585 titles and abstracts were screened, yielding 27 studies, of which five met eligibility criteria on full text assessment. These included 62 patients and 47 health professionals. Five themes emerged about patient attitudes: questioning preventive drugs; perceived benefit and risks, such as improving quality of life; patient preferences; trust in health professional judgement; and family, friends, and media influences. Five themes emerged about health professional attitudes: addressing patient concerns and information; duty as a health professional to prescribe; uncertainty about preventive drug prescribing; recognising consequences of prescribing, such as unnecessary medicalisation; and personalised treatment. CONCLUSION: The attitudes of patients and health professionals regarding drug initiation for primary prevention reflect the complexity of the patient-health professional encounter in primary practice. For prescribing to be more adherent to guidelines, research should further investigate the patient-health professional relationship and the appropriate communication methods required when discussing drug initiation, specifically for primary prevention.

A protocol for the development and piloting of quality measures to support the Healthier You: The NHS Diabetes Prevention Programme.

BACKGROUND: The increasing prevalence of type 2 diabetes in the UK creates an additional, potentially preventable burden on health care and service providers. The Healthier You: NHS Diabetes Prevention Programme aims to reduce the incidence of type 2 diabetes through the identification of people at risk and the provision of intensive lifestyle change support. The provision of this care can be monitored through quality measurement at both the general practice and specialist service level. AIM: To develop quality measures through piloting to assess the validity, credibility, acceptability, reliability, and feasibility of any proposed measures. DESIGN & SETTING: The non-experimental mixed design piloting study consists of consensus testing and exploratory research with GPs, commissioners, and patients from Herefordshire, England. METHOD: A mixed-method approach will be used to develop and validate measures for diabetes prevention care and evaluate their performance over a 6-month pilot period consisting of consensus testing using a modified RAND approach with GPs and commissioners; four focus groups with 8-10 participants discussing experiences of non-diabetic hyperglycaemia (NDH), perceived ability to access care and prevent diabetes, and views on potential quality measures; and piloting final measures with at least five general practices for baseline and 6-month data. RESULTS: The findings will inform the implementation of the diabetes prevention quality measures on a national scale while addressing any issue with validity, credibility, feasibility, and cost-effectiveness. CONCLUSION: Healthcare professionals and patients have the opportunity to evaluate the reliability, acceptability, and validity of measures.

The experience and influence of social support and social dynamics on cardiovascular disease prevention in migrant Pakistani communities: A qualitative synthesis.

OBJECTIVE: The objective of this research was to synthesise qualitative literature about the perceived influence and experience of social support, in relation to cardiovascular disease (CVD) prevention in migrant Pakistani communities. METHODS: Articles were systematically reviewed, critically appraised, and analysed using an adapted meta-ethnography approach. RESULTS: Sixteen qualitative studies on health behaviours related to CVD prevention were included. FINDINGS: include four sub-themes under two substantive thematic areas that focus on: 1) family dynamics and 2) community dynamics influenced by discrimination. For members of the Pakistani community, gendered family dynamics and discrimination from outside and within community networks influenced behaviour change. CONCLUSION: The authors of the synthesis developed multi-layered, contextualised interpretations of the care needs of an established multi-generational community. Future qualitative studies taking an intersectional approach to interpreting the role of social networks in migrant communities should take into account gender, identity, culture and faith. PRACTICE IMPLICATIONS: Health care providers should focus on cultural awareness and sensitivity during consultations. In particular, general practitioners can benefit from the insight they gain from patient experiences, allowing for more appropriate recommendations.