Clare Gerada: Dissecting resilience

The impact of shared social spaces on the wellness and learning of junior doctors: A scoping review

INTRODUCTION

Impaired wellness among junior doctors is a significant problem. Connectedness and sense of belonging may be important factors to prevent and reduce mental ill-health. Shared social spaces in which health care staff can meet informally are thought to improve connectedness; however, these spaces are in decline. It is unclear what is known about such spaces, how they are used, and their impact on wellness and learning. This study aims to identify and synthetise available literature that informs our current understanding of the nature of shared social spaces as an intervention impacting wellness and learning of junior doctors.

METHODS

A scoping review was conducted following the Arksey and O'Malley five-step framework. The review question is 'What is the evidence of the impact of shared social spaces on wellness and learning of junior doctors?' We searched five databases: MEDLINE, EMBASE, APA PsychINFO, APA PsychExtra, and ERIC. We conducted thorough supplementary searches in addition to the database search.

RESULTS

We included 41 articles. These were predominantly letters, commentaries, and editorials with only five primary research studies. We identified four significant common attributes of shared social spaces, which can be credited with positive impacts on wellness and learning: (1) Informal: fostering connectedness and belonging, trust and teamwork and offering access to informal help and support; (2) safe: allowing reflection, debrief and raising of concerns; (3) functional: there is planning of clinical care activity, sense of control and engagement from users and provision of refreshment; (4) legitimate: regular maintenance and use of shared social spaces affect role modelling, sustainability and wellness culture.

DISCUSSION

This review identified several ways in which shared social spaces impact positively on learning and wellness. There is little primary research in this area. Future research would be useful to further examine how and why this works.

The professional resilience of mid-career GPs in the UK: a qualitative study

Background

With a continued crisis of increasing workload and reduced workforce in general practice, supporting resilience is a key strategy for sustaining the profession into the future.

Aim

How do GPs perceive professional resilience, and what workplace factors influence it?

Design and setting

A UK-based qualitative study of the perspectives of GPs currently practicing in mainly urban locations across the UK with ≥5 years’ experience after completion of GP training.

Method

Participants were recruited using convenience sampling, which included social media forums, and underwent semi-structured interviews undertaken in May and June 2020 (n = 27). Data were analysed using thematic analysis.

Results

Participants offered definitions of and influences on resilience that largely fit with existing research, but in addition, may result in the perception that GPs are obstructive, or that resilience may be a ‘surface act’. GPs agree that the current focus on methods of improving resilience does support them, but there is significantly more to be done in this field. Social media activity aiming at GP support may be counterproductive. Reduction of clinical working hours is a common strategy to improve resilience.

Conclusion

That GPs feel to improve resilience they need to work fewer clinical hours may have huge implications for a workforce already in crisis, and ultimately, for the health care of the UK population. Urgent research is needed to formulate a bespoke assessment for measuring GP resilience to assess potential interventions, and to identify GPs at risk of mental ill-health or leaving the profession.

Interventions to minimise doctors’ mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review

Background

The growing incidence of mental ill-health in health professionals, including doctors, is a global concern. Although a large body of literature exists on interventions that offer support, advice and/or treatment to sick doctors, it has not yet been synthesised in a way that takes account of the complexity and heterogeneity of the interventions, and the many dimensions (e.g. individual, organisational, sociocultural) of the problem.

Objectives

Our aim was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health. The objectives were to review interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory; and recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

Design

Realist literature review consistent with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards quality and reporting standards.

Data sources

Bibliographic database searches were developed and conducted using MEDLINE (1946 to November week 4 2017), MEDLINE In-Process and Other Non-indexed Citations (1946 to 6 December 2017) and PsycINFO (1806 to November week 2 2017) (all via Ovid) and Applied Social Sciences Index and Abstracts (1987 to 6 December 2017) (via ProQuest) on 6 December 2017. Further UK-based studies were identified by forwards and author citation searches, manual backwards citation searching and hand-searching relevant journal websites.

Review methods

We included all studies that focused on mental ill-health; all study designs; all health-care settings; all studies that included medical doctors/medical students; descriptions of interventions or resources that focus on improving mental ill-health and minimising its impacts; all mental health outcome measures, including absenteeism (doctors taking short-/long-term sick leave); presenteeism (doctors working despite being unwell); and workforce retention (doctors leaving the profession temporarily/permanently). Data were extracted from included articles and the data set was subjected to realist analysis to identify context–mechanism–outcome configurations.

Results

A total of 179 out of 3069 records were included. Most were from the USA (45%) and had been published since 2009 (74%). More included articles focused on structural-level interventions (33%) than individual-level interventions (21%), but most articles (46%) considered both levels. Most interventions focused on prevention, rather than treatment/screening, and most studies referred to doctors/physicians in general, rather than to specific specialties or career stages. Nineteen per cent of the included sources provided cost information and none reported a health economic analysis. The 19 context–mechanism–outcome configurations demonstrated that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job, and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote well-being. Interventions creating a people-focused working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors needed to have confidence in an intervention for the intervention to be effective.

Limitations

Variable quality of included literature; limited UK-based studies.

Future work

Use this evidence synthesis to refine, implement and evaluate interventions.

Study registration

This study is registered as PROSPERO CRD42017069870.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 19. See the NIHR Journals Library website for further project information.

Optimising strategies to address mental ill-health in doctors and medical students: 'Care Under Pressure' realist review and implementation guidance

BACKGROUND

Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care-drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives-and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

METHODS

Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches-resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries.

RESULTS

One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective.

CONCLUSIONS

Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this.

STUDY REGISTRATION

PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup/.

Work-related post-traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO, a mixed-methods study with a cross-sectional survey and in-depth interviews

OBJECTIVES

To explore obstetricians' and gynaecologists' experiences of work-related traumatic events, to measure the prevalence and predictors of post-traumatic stress disorder (PTSD), any impacts on personal and professional lives, and any support needs.

DESIGN

Mixed methods: cross-sectional survey and in-depth interviews.

SAMPLE AND SETTING

Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG).

METHODS

A survey was sent to 6300 fellows, members and trainees of RCOG. 1095 people responded. Then 43 in-depth interviews with trauma-exposed participants were completed and analysed by template analysis.

MAIN OUTCOME MEASURES

Exposure to traumatic work-related events and PTSD, personal and professional impacts, and whether there was any need for support. Interviews explored the impact of trauma, what helped or hindered psychological recovery, and any assistance wanted.

RESULTS

Two-thirds reported exposure to traumatic work-related events. Of these, 18% of both consultants and trainees reported clinically significant PTSD symptoms. Staff of black or minority ethnicity were at increased risk of PTSD. Clinically significant PTSD symptoms were associated with lower job satisfaction, emotional exhaustion and depersonalisation. Organisational impacts included sick leave, and 'seriously considering leaving the profession'. 91% wanted a system of care. The culture in obstetrics and gynaecology was identified as a barrier to trauma support. A strategy to manage the impact of work-place trauma is proposed.

CONCLUSIONS

Exposure to work-related trauma is a feature of the experience of obstetricians and gynaecologists. Some will suffer PTSD with high personal, professional and organisational impacts. A system of care is needed.

TWEETABLE ABSTRACT

18% of obstetrics and gynaecology doctors experience post-traumatic stress disorder after traumatic events at work.