Filling in the gaps: A grounded theory of the experiences and needs of healthcare staff following a colleague death by suicide in the UK.

Health-workers are more likely to die by suicide than their counterparts in other occupational groups. The suicide of a staff member can be widely felt by colleagues, leading to complex emotional and cognitive responses. Exposure to suicide heightens the risk of dying by suicide. We investigated the impact of a colleague suicide on National Health Service (NHS) staff. Twenty-nine staff were interviewed; all participants were white British, and so not representative of the ethnic make-up of the NHS. Data were analyzed using grounded theory methods. A theory, "filling in the gaps" was developed. Staff experiences gave rise to needs that were not always met. Staff endeavored to "fill in the gaps" in support; however, sometimes fell through those gaps. Organizational and professional contexts shaped their experiences and responses. Recommendations include skilled and targeted support and compassion for affected staff. Cultural change is needed to challenge suicide stigma and unhelpful narratives.

Negotiating the postvention situation: A grounded theory of NHS staff experiences when supporting their coworkers following a colleague's suicide.

Suicide is a leading cause of death. NHS workers, especially female nurses, have heightened vulnerability. Being impacted by a colleague's suicide can lead to increased suicidality. Postvention refers to support following a suicide. We investigated current, available postvention for NHS workers following a colleague's suicide and the experiences of staff who deliver it ("supporters"). Twenty-two supporters were interviewed, and data were analyzed using classic grounded theory. The theory of negotiating postvention situations was developed. Supporters must negotiate enabling and disabling elements that form a "postvention situation" and impact behaviors and postvention efficacy. Postvention delivery is emotionally burdensome. Supporters need support, which they do not always receive. Postvention can lead to learning, which can better inform future postvention. The extent to which NHS workers can effectively support colleagues will depend on their postvention situation. As such, work must be done to enable supporters to offer effective postvention in the future.Suicide; postvention; healthcare workers; grounded theory.

Role of public health professionals in the climate and ecological crisis: a qualitative study.

BACKGROUND: The climate and ecological emergency is the single biggest health threat facing humanity, yet it is not clear to what extent the public health workforce have been involved in work on this topic. This research aimed to establish what public health consultants working in local authorities in England perceive their role to be, whether the climate crisis is seen as a core component of public health and to identify barriers to action. METHODS: Semi-structured interviews were undertaken with a purposive sample (n=11) of local authority public health consultants in England. Participants were recruited via public health organisations, social media or snowballing. Thematic content analysis was used to identify codes and themes. RESULTS: Public health professionals have started work on climate change but reported being unclear about their role and feeling isolated working on this topic. Barriers to action included shortage of financial resources, communication tools and capacity, limited sharing of best practice, lack of local expertise and conflict between the need for action on climate change and other urgent issues. CONCLUSION: We highlight the need to urgently address existing barriers to enable this important part of the public health workforce to play their role in tackling the climate and ecological crisis.

Vital role of clinicians in reducing the NHS carbon footprint through smarter procurement decisions.

BACKGROUND: The NHS' impact on the environment is significant, accounting for 5.9% of the national carbon footprint of the UK and 20 million tonnes of carbon dioxide equivalent (Mt CO2e) emissions a year.The procurement of goods and services is responsible for 72% of the NHS carbon footprint-equivalent to 15.2Mt CO2e. Procurement is, therefore, a priority focus area to consider, if carbon reductions are to be made. The impact of procurement decisions extends over the 'whole life'-from identification of the need for a product or service through to the provision of the product or service and including the product's 'end of life' process (disposal).From April this year, any new procurement needs to have a 10% net zero and social value weighting. From April 2023 onward, any new procurement two times per day should incorporate carbon footprint and environmental impact.This paper aims to introduce clinicians to the concept of green procurement and illustrate the potential greenhouse gases savings possible if procurement decisions were informed by the sustainability credentials such as the carbon footprint of a product or the corporate social responsibility programme of the supplier. METHODS: While seconded at the Department of Health and Social Care, the senior author on this paper collaborated with the NHS Supply Chain to pilot carbon footprinting of one clinical item. We chose to focus on the 20-gauge 'pink' cannula as a high-volume familiar article; 25 million cannulas are purchased via the NHS Supply Chain each year, of which the most commonly used size is the 20 gauge. RESULTS: Of the seven companies approached, five sent us their CSR strategies. Four companies provided product primary data, and of these four, one provided sufficient data to carry out a carbon footprint analysis. The one set of detailed data provided was for two 20-gauge cannulas, 1 with wings and 1 without. The total carbon footprint for Cannula 1 is 33.92 g CO2e. The total carbon footprint for Cannula 2 is 35.45 g CO2e. This amounts to a 1.54 g CO2e difference between the 2 cannulas. CONCLUSION: It is both necessary and possible for the NHS to demonstrate leadership in reducing the carbon footprint of healthcare.We have provided an overview of NHS procurement to empower clinicians to get involved with local and national decision-making. We have demonstrated the potential carbon savings that could be made through careful choice of products. We have also highlighted the risks if clinicians do not engage with green procurement.

Working conditions, psychological distress and suicidal ideation: cross-sectional survey study of UK junior doctors.

BACKGROUND: Evidence attests a link between junior doctors' working conditions and psychological distress. Despite increasing concerns around suicidality among junior doctors, little is known about its relationship to their working conditions. AIMS: To (a) establish the prevalence of suicidal ideation among junior doctors in the National Health Service; (b) examine the relationships between perceived working conditions and suicidal ideation; and (c) explore whether psychological distress (e.g. symptoms of depression and anxiety) mediates these relationships. METHOD: Junior doctors were recruited between March 2020 and January 2021, for a cross-sectional online survey. We used the Health and Safety Executive's Management Standards Tool; Depression, Anxiety and Stress Scale 21; and Paykel Suicidality Scale to assess working conditions, psychological distress and suicidality, respectively. RESULTS: Of the 424 participants, 50.2% reported suicidal ideation, including 6.1% who had made an attempt on their own life. Participants who identified as LGBTQ+ (odds ratio 2.18, 95% CI 1.15-4.12) or reported depression symptoms (odds ratio 1.10, 95% CI 1.07-1.14) were more likely to report suicidal ideation. No direct relationships were reported between working conditions (i.e. control, support, role clarity, strained relationships, demand and change) and suicidal ideation. However, depression symptoms mediated all six relationships. CONCLUSIONS: This sample of junior doctors reported alarming levels of suicidal ideation. There may be an indirect relationship between working conditions and suicidal ideation via depressive symptoms. Clearer research exploring the experience of suicidality in junior doctors is needed, including those who identify as LGBTQ+. Systematic interventions addressing working environment are needed to support junior doctors' mental health.

Trends Over Time in the Use, Carbon Footprint and Costs of Facet Joint Injections and Medial Branch Blocks to Manage Lumbar Pain in England: Retrospective Analysis of an Administrative Dataset.

STUDY DESIGN: Retrospective analysis of an administrative dataset. OBJECTIVE: This study aims to investigate changing practice over a six-year period in the use of repeated lumbar facet joint injections/medial branch blocks in England. METHODS: Patient data were extracted from the Hospital Episodes Statistics database for the period 1st April 2015 to 31st March 2021 for the index lumbar injection and for repeat lumbar injections performed within one year of the first. The exposure of interest was two injections within 180 days or three within one year. Patients aged <17 years and where the body site was listed as cervical, thoracic or sacral were excluded. RESULTS: Data were available for 134,249 patients of which, 8,922 (6.6%) had either two injections within 180 days or three injections within one year. First injections fell from 42,511 in 2015/16 to 13,368 in 2019/20 as did the number of repeat injections: 4,018 to 424 for the same period. If all years had the same carbon footprint as 2019/20, 2.8 kilotons of CO2e would have been saved over the five years, enough to power 2,575 average UK homes for 1 year. The financial cost of injections decreased from £27.6 million in 2015/16 to £7.9 million in 2019/20. CONCLUSIONS: The number of patients having repeated lumbar injections has decreased over time but has not been eliminated. More work is needed to educate patients and clinicians regarding alternative and more effective treatments.

Potential Carbon Savings with Day-case Compared to Inpatient Transurethral Resection of Bladder Tumour Surgery in England: A Retrospective Observational Study Using Administrative Data.

Background: The National Health Service (NHS) in England has set a net-zero target for carbon emissions by 2040. Increasing use of day-case surgery pathways may help in meeting this target. Objective: To investigate the estimated difference in carbon footprint between day-case and inpatient transurethral resection of bladder tumour (TURBT) surgery in England. Design setting and participants: This was a retrospective analysis of administrative data extracted from the Hospital Episode Statistics database for all TURBT procedures conducted in England from April 1, 2013 to March 31, 2022. Outcome measurements and statistical analysis: Day-case and inpatient TURBT procedures were identified and the carbon footprint for key elements of the surgical pathway was estimated using data from Greener NHS and the Sustainable Healthcare Coalition. Results and limitations: Of 209 269 TURBT procedures identified, 41 583 (20%) were classified as day-case surgery. The day-case rate increased from 13% in 2013-2014 to 31% in 2021-2022. The move from inpatient stays to day-case surgery between 2013-2014 and 2021-2022 demonstrates a trend toward a lower-carbon pathway, with an estimated saving of 2.9 million kg CO2 equivalents (equivalent to powering 2716 homes for 1 yr) in comparison to no change in practice. We calculated that potential carbon savings for the financial year 2021-2022 would be 217 599 kg CO2 equivalents (equivalent to powering 198 homes for 1 yr) if all hospitals in England not already in the upper quartile were able to achieve the current upper-quartile day-case rate. Our study is limited in that estimates are based on carbon factors for generic surgical pathways. Conclusions: Our study highlights potential NHS carbon savings that could be achieved by moving from inpatient stays to day-case surgery. Reducing variation in care across the NHS and encouraging all hospitals to adopt day-case surgeries, where clinically appropriate, would lead to further carbon savings. Patient summary: In this study we estimated the potential for carbon savings if patient undergoing bladder tumour surgery were admitted and discharged on the same day. We estimate that increasing use of day-case surgery between 2013-2014 and 2021-2022 has saved 2.9 million kg CO2 equivalents. If all hospitals were to achieve day case-rates comparable to those in the highest quarter of hospitals in England in 2021-2022, then the carbon equivalent to powering 198 homes for 1 year could have been saved.

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.

An outbreak of Cryptosporidium parvum linked to pasteurised milk from a vending machine in England: a descriptive study, March 2021.

We describe the investigations and management of a Cryptosporidium parvum outbreak of linked to consumption of pasteurised milk from a vending machine. Multiple locus variable number of tandem repeats analysis was newly used, confirming that C. parvum detected in human cases was indistinguishable from that in a calf on the farm. This strengthened the evidence for milk from an on-farm vending machine as the source of the outbreak because of post-pasteurisation contamination. Bacteriological indicators of post-pasteurisation contamination persisted after the initial hygiene improvement notice. We propose that on-farm milk vending machines may represent an emerging public health risk.

The Impact of Colleague Suicide and the Current State of Postvention Guidance for Affected Co-Workers: A Critical Integrative Review.

People bereaved by suicide are affected psychologically and physically and may be at greater risk of taking their own lives. Whilst researchers have explored the impact of suicide on family members and friends, the area of colleague suicide has been neglected and postvention guidance for supporting surviving colleagues is often poorly developed. This critical integrative review explored the impact of colleague suicide on surviving co-workers and reviewed postvention guidance for workplaces. Systematic searches found 17 articles that met the inclusion criteria. Articles were appraised for quality and extracted data were analysed using a thematic network method. Article quality was moderate. Two global themes were developed: impact of a colleague suicide comprised themes of 'suicide loss in the workplace'; 'professional identities and workplace roles'; 'perceptions of professional uniqueness'; and 'professional abandonment and silencing'. Postvention following a colleague suicide comprised 'individualised responses'; 'the dual function of stigma'; and 'complex pressure on managers'. A unifying global network 'after a colleague suicide' describes the relationships between all themes. A series of disconnects between existing postvention guidance and the needs of impacted workers are discussed. This review demonstrates the need for robust, systemic postvention for colleagues impacted by the complex issue of colleague suicide.

Relationship between working conditions and psychological distress experienced by junior doctors in the UK during the COVID-19 pandemic: a cross-sectional survey study.

OBJECTIVES: This paper explored the self-reported prevalence of depression, anxiety and stress among junior doctors during the COVID-19 pandemic. It also reports the association between working conditions and psychological distress experienced by junior doctors. DESIGN: A cross-sectional online survey study was conducted, using the 21-item Depression, Anxiety and Stress Scale and Health and Safety Executive scale to measure psychological well-being and working cultures of junior doctors. SETTING: The National Health Service in the UK. PARTICIPANTS: A sample of 456 UK junior doctors was recruited online during the COVID-19 pandemic from March 2020 to January 2021. RESULTS: Junior doctors reported poor mental health, with over 40% scoring extremely severely depressed (45.2%), anxious (63.2%) and stressed (40.2%). Both gender and ethnicity were found to have a significant influence on levels of anxiety. Hierarchical multiple linear regression analysis outlined the specific working conditions which significantly predicted depression (increased demands (ß=0.101), relationships (ß=0.27), unsupportive manager (ß=-0.111)), anxiety (relationships (ß=0.31), change (ß=0.18), demands (ß=0.179)) and stress (relationships (ß=0.18), demands (ß=0.28), role (ß=0.11)). CONCLUSIONS: The findings illustrate the importance of working conditions for junior doctors' mental health, as they were significant predictors for depression, anxiety and stress. Therefore, if the mental health of junior doctors is to be improved, it is important that changes or interventions specifically target the working environment rather than factors within the individual clinician.

What challenges did junior doctors face while working during the COVID-19 pandemic? A qualitative study.

OBJECTIVES: This paper reports findings exploring junior doctors' experiences of working during the COVID-19 pandemic in the UK. DESIGN: Qualitative study using in-depth interviews with 15 junior doctors. Interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.12 to facilitate data management. Data were analysed using reflexive thematic analysis. SETTING: National Health Service (NHS) England. PARTICIPANTS: A purposive sample of 12 female and 3 male junior doctors who indicated severe depression and/or anxiety on the DASS-21 questionnaire or high suicidality on Paykel's measure were recruited. These doctors self-identified as having lived experience of distress due to their working conditions. RESULTS: We report three major themes. First, the challenges of working during the COVID-19 pandemic, which were both personal and organisational. Personal challenges were characterised by helplessness and included the trauma of seeing many patients dying, fears about safety and being powerless to switch off. Work-related challenges revolved around change and uncertainty and included increasing workloads, decreasing staff numbers and negative impacts on relationships with colleagues and patients. The second theme was strategies for coping with the impact of COVID-19 on work, which were also both personal and organisational. Personal coping strategies, which appeared limited in their usefulness, were problem and emotion focused. Several participants appeared to have moved from coping towards learnt helplessness. Some organisations reacted to COVID-19 collaboratively and flexibly. Third, participants reported a positive impact of the COVID-19 pandemic on working practices, which included simplified new ways of working-such as consistent teams and longer rotations-as well as increased camaraderie and support. CONCLUSIONS: The trauma that junior doctors experienced while working during COVID-19 led to powerlessness and a reduction in the benefit of individual coping strategies. This may have resulted in feelings of resignation. We recommend that, postpandemic, junior doctors are assigned to consistent teams and offered ongoing support.

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.

Integrating sustainability into postgraduate medical education.

The delivery of healthcare is a major contributor to the climate crisis, with the NHS being the largest public sector contributor of carbon emissions in the UK. Physicians have an important role to play in the fight against climate change through the practice of sustainable healthcare. This involves maintaining the current and future quality of healthcare through balancing environmental, social and financial constraints. To this end, integrating these skills into medical education is crucial. A large number of medical schools have already embedded planetary health and sustainability theory into their curriculum, however, there is no formal sustainability curriculum in postgraduate education and training. This is vital for enabling clinicians to translate sustainability theory taught at undergraduate level into clinical practice. This article proposes which topics should be included in a postgraduate sustainability curriculum and explores various methods that could be used to incorporate these into the current educational framework.

Trends in anticoagulant prescribing: a review of local policies in English primary care.

BACKGROUND: Oral anticoagulants are prescribed for stroke prophylaxis in patients with atrial fibrillation, which is the most common heart arrhythmia worldwide. The vitamin K antagonist (VKA) warfarin is a long-established anticoagulant. However, newer direct oral anticoagulants (DOACs) have been recently introduced as an alternative. Given the prevalence of atrial fibrillation, anticoagulant choice has substantial clinical and financial implications for healthcare systems. In this study, we explore trends and geographic variation in anticoagulant prescribing in English primary care. Because national guidelines in England do not specify a first-line anticoagulant, we investigate the association between local policies and prescribing data. METHODS: Primary care prescribing data of anticoagulants for all NHS practices from 2014 to 2019 in England was obtained from the ePACT2 database. Public formularies were accessed online to obtain local anticoagulation prescribing policies for 89.5% of clinical commissioning groups (CCGs). These were categorized according to their recommendations: no local policies, warfarin as first-line, or identification of a preferred DOAC (but not a preferred anticoagulant). Local policies were cross-tabulated with pooled prescribing data to measure the strength of association with Cramér's V. RESULTS: Nationally, prescribing of DOACs increased from 9% of all anticoagulants in 2014 to 74% in 2019, while that of warfarin declined accordingly. Still, there was significant local variation. Across geographical regions, DOACs ranged from 53 to 99% of all anticoagulants. Most CCGs (73%) did not specify a first-line choice, and 16% recommended warfarin first line. Only 11% designated a preferred DOAC. Policies with a preferred DOAC indeed correlated with increased prescribing of that DOAC (Cramér's V = 0.25, 0.27, 0.38 for rivaroxaban, apixaban, edoxaban respectively). However, local policies showed a negligible relationship with the classes of anticoagulants prescribed-DOAC or VKA (Cramér's V = 0.01). CONCLUSIONS: Nationally, the use of DOACs to treat atrial fibrillation has increased rapidly. Despite this, significant geographical variation in uptake remains. This study provides insights on how local policies relate to this variation. Our findings suggest that, in the absence of a nationally recommended first-line anticoagulant, local prescribing policies may aid in deciding between individual DOACs, but not in adjudicating between DOACs and vitamin K antagonists (i.e. warfarin) as general classes.