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.

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.

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.

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.

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.

What do public health professionals think their role is in tackling the climate and ecological emergency? A qualitative study

BACKGROUND

The climate and ecological emergency is the single biggest health threat facing humanity. However, it is not universally seen as a priority for public health. It is not clear to what extent public health professionals are involved in working on the climate and ecological emergency. This research aimed to establish what senior public health professionals working in English local authorities perceive their role is, what activities they are involved in, whether climate and environmental issues are a core component of public health, and to identify barriers to action.

METHODS

Semi-structured interviews were done with a purposive sample of 15 local authority public health consultants and directors of public health in England using a predefined and piloted topic guide over a Zoom session. Participants were recruited via national public health bodies, social media, or snowballing. Thematic content analysis was used to identify codes and key themes. Ethical exemption was obtained from the University of Manchester.

FINDINGS

Some public health professionals have started work on climate change and others were unclear about the role of public health. Key activities included establishing governance structures, bringing together stakeholders, making the case for health co-benefits of climate action, and advocating for reducing inequalities while reducing carbon emissions. Barriers to action included shortage of financial resources, communication tools and capacity, little sharing of best practice, scarcity of local expertise, and conflict between the need for action on climate change and other urgent public health issues.

INTERPRETATION

Public health professionals increasingly work on climate change, but practice would be strengthened by improved intelligence, more resources, and support networks. This new qualitative data can inform the development of the role of public health professionals in climate change and the ecological emergency. However, a limitation on the study was that only able to engage public health consultants who considered the climate and ecological crisis as important for public health, so it remains unclear in how far our findings represent the views of the larger public health community.

FUNDING

None.

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 (β=0.101), relationships (β=0.27), unsupportive manager (β=-0.111)), anxiety (relationships (β=0.31), change (β=0.18), demands (β=0.179)) and stress (relationships (β=0.18), demands (β=0.28), role (β=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.

Mapping the movement for climate change and health in England: a descriptive review and theory of change analysis

Aims:

There are a growing number of organisations working to address the connections between climate change and health. This article introduces the concept of ‘theories of change’ – the methodology by which organisations or movements hope to bring about social change – and applies it to the current climate change and health movement in England. Through movement mapping, the article describes and offers reflections on the climate change and health ecosystems in England.

Methods:

Organisations working on climate change and health in England were identified and publicly available information was collated to map movement characteristics, target stakeholders and methodologies deployed, using an inductive, iterative approach.

Results:

A total of 98 organisations working on health and climate change (and/or sustainability) were initially identified, of which 70 met the inclusion criteria. Most organisations target two or more stakeholders, with healthcare workers, management structures, and government being most commonly cited. Methodological approaches identified include Formal education programmes; Awareness-raising; Purchasing-procurement power; Advocacy; Financial; Media-messaging; Networking; Knowledge generation; and Policy making, of which education, awareness-raising, and advocacy are most commonly used.

Conclusion:

There is a tendency for climate change and health organisations in England to focus on individual level and sectoral change over system change. More could be made of the potential for the healthcare professions’ voice and messaging for the wider climate movement. Given the rapid boom of climate change and health organisations in recent years, a mind-set shift that recognises different players as part of a cohesive ecosystem with better coordination and collaboration may reduce unnecessary work, and facilitate more cohesive 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.

Going upstream - an umbrella review of the macroeconomic determinants of health and health inequalities

BACKGROUND

The social determinants of health have been widely recognised yet there remains a lack of clarity regarding what constitute the macro-economic determinants of health and what can be done to address them. An umbrella review of systematic reviews was conducted to identify the evidence for the health and health inequalities impact of population level macroeconomic factors, strategies, policies and interventions.

METHODS

Nine databases were searched for systematic reviews meeting the Database of Abstracts of Reviews of Effects (DARE) criteria using a novel conceptual framework. Studies were assessed for quality using a standardised instrument and a narrative overview of the findings is presented.

RESULTS

The review found a large (n = 62) but low quality systematic review-level evidence base. The results indicated that action to promote employment and improve working conditions can help improve health and reduce gender-based health inequalities. Evidence suggests that market regulation of tobacco, alcohol and food is likely to be effective at improving health and reducing inequalities in health including strong taxation, or restriction of advertising and availability. Privatisation of utilities and alcohol sectors, income inequality, and economic crises are likely to increase health inequalities. Left of centre governments and welfare state generosity may have a positive health impact, but evidence on specific welfare interventions is mixed. Trade and trade policies were found to have a mixed effect. There were no systematic reviews of the health impact of monetary policy or of large economic institutions such as central banks and regulatory organisations.

CONCLUSIONS

The results of this study provide a simple yet comprehensive framework to support policy-makers and practitioners in addressing the macroeconomic determinants of health. Further research is needed in low and middle income countries and further reviews are needed to summarise evidence in key gaps identified by this review.

TRIAL REGISTRATION

Protocol for umbrella review prospectively registered with PROSPERO CRD42017068357.

Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention

BACKGROUND AND OBJECTIVES

Patients with decompensated cirrhosis rarely receive palliative and supportive care interventions, which are routine in other life-limiting diseases. We aimed to design and evaluate a prognostic screening tool to routinely identify inpatients with decompensated cirrhosis at high risk of dying over the coming year, alongside the development of a supportive care intervention.

DESIGN

Clinical notes from consecutive patients admitted as an emergency to University Hospitals Bristol with a diagnosis of cirrhosis over two distinct 90-day periods were scrutinised retrospectively for the presence or absence of five evidence-based factors associated with poor prognosis. These were analysed against their ability to predict mortality at 1 year. 'Plan-Do-Study-Act' (PDSA) methodology was used to incorporate poor-prognosis screening into the routine assessment of patients admitted with cirrhosis, and develop a supportive care intervention.

RESULTS

73 admissions were scrutinised (79.5% male, 63% alcohol-related liver disease, median age 54). The presence of three or more poor-prognosis criteria at admission predicted 1-year mortality with sensitivity, specificity and positive predictive value of 72.2%, 83.8% and 81.3%, respectively, and was used as a trigger for implementing the supportive care intervention. Following modification from six PDSA cycles, prognostic screening was integrated into the assessment of all patients admitted with decompensated cirrhosis, with the supportive care intervention (developed simultaneously) instigated for appropriate patients.

CONCLUSIONS

We describe a model of care which identifies inpatients with cirrhosis at significant risk of dying over the coming year, and describe development of a supportive care intervention, which can be offered to suitable patients in parallel to ongoing active management.