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.

Clinicians' Perspectives on Self-Harm in Pakistan: A Qualitative Study.

Background: Suicide is a serious public health problem, ranked amongst the leading causes of death worldwide. There are no official data on self-harm and suicide in Pakistan; both are illegal acts, and are socially and religiously condemned. This study explored the views of clinicians, including general practitioners (GPs) and hospital physicians (HPs) on self-harm, about their management of people who self-harm and what interventions might be appropriate in Pakistan. Methods: This qualitative study, generating data using semi-structured interviews, was nested within a Randomized Controlled Trial (RCT) of a psychosocial intervention for people following self-harm. Clinicians (n = 18) with experience of treating people who self-harm were recruited from public hospitals and general practices. Results: Face-to-face interviews were conducted in Urdu and digitally recorded with consent, transcribed and translated into English. Transcripts were checked for cultural and interpretive interpretations by the research team, then analyzed thematically using the principles of constant comparison. The following themes will be presented: encountering people with self-harming behaviors; challenges encountered in managing people who self-harm; barriers to accessing care, and what ideal care might look like. Participants identified their lack of training and expertise in the management of people with self-harm behavior. Conclusions: This is the first study to explore clinicians' perspectives on self-harm in Pakistan. The study highlighted the need for training for doctors in the identification and management of mental health problems, including the management of people who self-harm.

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.

'Reluctant pioneer': A qualitative study of doctors' experiences as patients with long COVID.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has had far-reaching effects upon lives, healthcare systems and society. Some who had an apparently 'mild' COVID-19 infection continue to suffer from persistent symptoms, including chest pain, breathlessness, fatigue, cognitive impairment, paraesthesia, muscle and joint pains. This has been labelled 'long COVID'. This paper reports the experiences of doctors with long COVID. METHODS: A qualitative study; interviews with doctors experiencing persistent symptoms were conducted by telephone or video call. Interviews were transcribed and analysis conducted using an inductive and thematic approach. RESULTS: Thirteen doctors participated. The following themes are reported: making sense of symptoms, feeling let down, using medical knowledge and connections, wanting to help and be helped, combining patient and professional identity. Experiencing long COVID can be transformative: many expressed hope that good would come of their experiences. Distress related to feelings of being 'let down' and the hard work of trying to access care. Participants highlighted that they felt better able to care for, and empathize with, patients with chronic conditions, particularly where symptoms are unexplained. CONCLUSIONS: The study adds to the literature on the experiences of doctors as patients, in particular where evidence is emerging and the patient has to take the lead in finding solutions to their problems and accessing their own care. PATIENT AND PUBLIC CONTRIBUTION: The study was developed with experts by experience (including co-authors HA and TAB) who contributed to the protocol and ethics application, and commented on analysis and implications. All participants were given the opportunity to comment on findings.

Finding the 'right' GP: a qualitative study of the experiences of people with long-COVID.

BACKGROUND: An unknown proportion of people who had an apparently mild COVID-19 infection continue to suffer with persistent symptoms, including chest pain, shortness of breath, muscle and joint pains, headaches, cognitive impairment ('brain fog'), and fatigue. Post-acute COVID-19 ('long-COVID') seems to be a multisystem disease, sometimes occurring after a mild acute illness; people struggling with these persistent symptoms refer to themselves as 'long haulers'. AIM: To explore experiences of people with persisting symptoms following COVID-19 infection, and their views on primary care support received. DESIGN & SETTING: Qualitative methodology, with semi-structured interviews to explore perspectives of people with persisting symptoms following suspected or confirmed COVID-19 infection. Participants were recruited via social media between July-August 2020. METHOD: Interviews were conducted by telephone or video call, digitally recorded, and transcribed with consent. Thematic analysis was conducted applying constant comparison techniques. People with experience of persisting symptoms contributed to study design and data analysis. RESULTS: This article reports analysis of 24 interviews. The main themes include: the ' hard and heavy work ' of enduring and managing symptoms and accessing care; living with uncertainty, helplessness and fear, particularly over whether recovery is possible; the importance of finding the 'right' GP (understanding, empathy, and support needed); and recovery and rehabilitation: what would help? CONCLUSION: This study will raise awareness among primary care professionals, and commissioners, of long-COVID and the range of symptoms people are experiencing. Patients require their GP to believe their symptoms and to demonstrate empathy and understanding. Ongoing support by primary care professionals during recovery and rehabilitation is crucial.

'Treading water but drowning slowly': what are GPs' experiences of living and working with mental illness and distress in England? A qualitative study.

OBJECTIVES: This paper provides an in-depth account of general practitioners' (GPs) experiences of living and working with mental illness and distress, as part of a wider study reporting the barriers and facilitators to help-seeking for mental illness and burn-out, and sources of stress/distress for GP participants. DESIGN: Qualitative study using in-depth interviews with 47 GP 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: England. PARTICIPANTS: A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face to face or over the telephone. RESULTS: The findings report GP participants' in-depth experiences of distress and mental illness with many recollecting their distressing experiences and significant psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out, and a quarter articulating thoughts of suicide. Many talked about their shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental illness. CONCLUSIONS: These findings paint a concerning picture of the situation affecting primary care doctors, with participants' accounts suggesting there is a considerable degree of mental ill health and reduced well-being among GPs. The solutions are complex and lie in prevention and provision. There needs to be greater recognition of the components and cumulative effect of occupational stressors for doctors, such as the increasing workload and the clinical and emotional demands of the job, as well as the need for a culture shift within medicine to more supportive and compassionate work environments.

Discrimination, harassment and non-reporting in UK medical education.

CONTEXT: Discrimination and harassment create a hostile environment with deleterious effects on student well-being and education. In this study, we aimed to: (i) measure prevalences and types of discrimination and harassment in one UK medical school, and (ii) understand how and why students report them. METHODS: The study used a mixed-methods design. A medical school population survey of 1318 students was carried out in March 2014. Students were asked whether they had experienced, witnessed or reported discrimination or harassment and were given space for free-text comments. Two focus group sessions were conducted to elicit information on types of harassment and the factors that influenced reporting. Proportions were analysed using the Wilson score method and associations tested using chi-squared and regression analyses. Qualitative data were subjected to framework analysis. Degrees of convergence between data were analysed. RESULTS: A total of 259 (19.7%) students responded to the survey. Most participants had experienced (63.3%, 95% confidence interval [CI]: 57.3-69.0) or witnessed (56.4%, 95% CI: 50.3-62.3) at least one type of discrimination or harassment. Stereotyping was the form most commonly witnessed (43.2%, 95% CI: 37.4-49.3). In the qualitative data, reports of inappropriate joking and invasion of personal space were common. Black and minority ethnic students had witnessed and religious students had experienced a greater lack of provision (χ2  = 4.73, p = 0.03 and χ2  = 4.38, p = 0.04, respectively). Non-heterosexual students had experienced greater joking (χ2  = 3.99, p = 0.04). Students with disabilities had experienced more stereotyping (χ2  = 13.5, p < 0.01). Female students and students in clinical years had 2.6 (95% CI: 1.3-5.3) and 3.6 (95% CI: 1.9-7.0) greater odds, respectively, of experiencing or witnessing any type of discrimination or harassment. Seven of 140 survey respondents had reported incidents (5.0%, 95% CI: 2.4-10.0). Reporting was perceived as ineffective and as potentially victimising of the reporter. CONCLUSIONS: Harassment and discrimination are prevalent in this sample and associated with gender, ethnicity, sexuality, disability and year group. Reporting is rare and perceived as ineffective. These findings have informed local developments, future strategies and the development of a national prevention policy.

Implementation of teaching on LGBT health care.

BACKGROUND: Lesbian, gay, bisexual and transgender (LGBT) patients represent an important proportion of the population. Despite the health inequalities and barriers to health care noted within this group, there is little evidence of LGBT-focused education within medicine, dentistry or nursing. We introduced and evaluated the effect of a half-day teaching session focused on LGBT health care, delivered to year-2 students. CONTEXT: Initial informal discussion with year-2 and year-3 students suggested that the awareness of health inequalities other than sexual health was limited, and that students had little awareness of other issues such as gender dysphoria and heterosexism. We therefore targeted these areas when developing the material. There is little evidence of LGBT-focused education within medicine, dentistry or nursing INNOVATION: The session was divided into two sections: a lecture and a workshop. The lecture provided an introduction to issues around legislation, transgender health and health inequalities, whereas the workshops involved a role-play focused on gender dysphoria, followed by small group discussions on topics such as heterosexism and sexual identity. Volunteer peer facilitators, some of whom identified as LGBT, undertook a 2-hour training session to ensure that they were comfortable with both the material and the group facilitation. Students completed a short questionnaire before and after the session. IMPLICATIONS: Feedback was gathered from 350 students between 2012 and 2015. Sixty-nine per cent of students rated their competency level higher after the workshop, suggesting that they felt better prepared to consult with LGBT patients. Written comments suggested that the sessions are useful for students in terms of improving awareness of health inequalities and enabling consultation skills practice in an informal environment.

'It's personal to me': A qualitative study of depression in young people with CFS/ME.

BACKGROUND: Paediatric chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) has a prevalence of 0.4-2.4% and is defined as 'generalised disabling fatigue persisting after routine tests and investigations have failed to identify an obvious underlying cause'. One-third of young people with CFS/ME have probable depression. Little is known about why depression develops, the relationship between depression and CFS/ME, or what treatment might be helpful. METHODS: We conducted nine semi-structured interviews with young people with CFS/ME (aged 13-17 years, 8/9 female) and probable depression, covering perceived causes of depression, the relationship between CFS/ME and depression, and treatment strategies. RESULTS: Most thought CFS/ME caused depression. Many discussed a cyclical relationship: low mood made CFS/ME worse. A sense of loss was common. CFS/ME restricted activities participants valued and changed systemic structures, causing depression. There was no single helpful treatment approach. Individualised approaches using combinations of cognitive behavioural therapy (CBT), medication, activity management and other strategies were described. CONCLUSION: This study suggests that depression may be secondary to CFS/ME in young people because of the impact of CFS/ME on quality of life. Clinicians treating young people with CFS/ME need to consider strategies to prevent development of depression, and research is needed into approaches that are effective in treating CFS/ME with co-morbid depression.

Railway suicide in England and Wales 2000-2013: a time-trends analysis.

BACKGROUND: In 2010, the "Tackling Suicide on the Railways" programme was launched as a joint initiative among Network Rail, the Samaritans and other key organisations such as the British Transport Police and train operators to achieve a 20% reduction in railway suicides from 2010 to 2015 in Great Britain. We report the most recent age and sex specific trends in railway suicide in England and Wales from 2000 to 2013 and examine whether the initiative's target reduction in railway suicides is likely to be achieved. METHODS: Population data and suicide mortality data (all methods combined and railway) for England and Wales were obtained from the Office for National Statistics (ONS) and used to calculate age and gender specific rates for deaths registered from 2000 to 2013. Data on railway suicides were also obtained from the Rail Safety and Standards Board (RSSB) and compared with ONS data. We used joinpoint regression to identify changes in suicide trends across the study period. RESULTS: The railway was used in 4.1% of all suicides in England and Wales (RSSB data were similar to ONS data for most years). Suicides in all persons from all causes decreased from 2000 to 2007, with small increases from 2008 until 2013; this rise was entirely due to an increase in male suicides. Railway suicide rates increased over the entire study period; the proportion of railway suicides in all persons increased from 3.5 to 4.9% during the study period. This trend was also mainly driven by increases in male suicides as female railway suicide rates remained steady over time. The highest age specific railway suicide rates were observed in middle aged men and women. Although there was no conclusive evidence of an increase in ONS railway suicides, RSSB data showed a statistically significant increase in railway suicides in males from 2009 onwards. CONCLUSION: The continued rise in male railway suicide in England and Wales is concerning, particularly due to the high economic costs and psychological trauma associated with these deaths. The initiative's target of a 20% reduction in railway suicide is unlikely to be achieved.

Access to healthcare for long-term conditions in women involved in street-based prostitution: a qualitative study.

BACKGROUND: Women involved in street-based prostitution (SBP) have well-documented health problems specific to their occupation, but access to care for other chronic health problems has not been explored. Primary care is seen as the optimal context to deliver care for people with long-term conditions because it is accessible, efficient, and can tackle inequalities related to socioeconomic deprivation. We aimed to explore the perspectives of women involved in SBP about access to health care for their long-term conditions. METHODS: This was a qualitative study with women accessing a third sector organization in North West England. Semi-structured interviews were conducted with sixteen women involved in SBP and accessing support. Data were analysed using the principles of constant comparison and a framework approach. RESULTS: Women described how they were living with ill health, which they found difficult to manage, and often impacted on their work. Women reported poor access to care and viewed any ensuing consultations in primary care as unsatisfactory. CONCLUSION: This study highlights the unmet health needs of women who work in SBP, not just related to their occupation, but due to their co-morbid long-term conditions. Access to primary care was reported to be problematic and interactions with general practitioners not fulfilling their expectations, which impacted on future consultation behaviour. Understanding the health-seeking behaviours and self-management strategies of women involved in SBP with chronic health problems is essential in the design and commissioning of services and may reduce unscheduled care in this under-served group.

The long-term outcome of children managed with extracorporeal life support: an institutional experience.

OBJECTIVE: To evaluate the long-term functional status and quality of life of infants and children who have received extracorporeal life support (ECLS), and to determine how and when death occurred. DESIGN: Long-term, prospective follow-up study. SETTING: 16-bed paediatric intensive care unit in a university teaching hospital. PARTICIPANTS: All children who received ECLS in the period April 1988 to October 2000 in the paediatric ICU at the Royal Children's Hospital, Melbourne, VIC. METHODS: The records of all 224 children who had received ECLS were reviewed, and functional status and quality of life were assessed through interview with each child's parent or guardian for those who had survived. RESULTS: Follow-up information was available for 211 children at a median of 7.2 years (range, 3.9 months to 12.6 years) after admission to the paediatric ICU. Sixty-nine children were alive at follow-up, 96% of whom were likely to lead an independent existence. Of the 142 deaths, 123 occurred in the paediatric ICU: 74 were due to elective withdrawal of therapy for poor prognosis, and eight for brain death; 30 were disease-related; seven were ECLSrelated; and four were due to sepsis. CONCLUSIONS: ECLS is a complex therapy which has been used in Australian children for 18 years; a third of children survived long term, and 96% of these had a favourable outcome.