Bullying workshops for obstetric trainees: a way forward

BACKGROUND

In sector-wide surveys, trainees in obstetrics and gynaecology have consistently reported the experience of being undermined in the workplace. Bullying has serious implications within the UK's National Health Service (NHS), for both the individual experiencing it and the wider system.

CONTEXT

Obstetrics and gynaecology is a high-pressure specialty: the workload is intense, staffing is often suboptimal and litigation levels are high. Obstetrics alone accounted for 50 per cent of litigation claims in the NHS in 2012. This 'cocktail', when combined with the target-based management style common in the current financial climate, easily lends itself to a culture of bullying.

INNOVATION

In order to manage this problem a workshop was developed with the initial aim of raising awareness, entitled 'Undermining and Harassment: A Practical Workshop for Trainees'. A typical workshop comprises the following interlinking topics relevant to bullying: (1) what is bullying (interactive session); (2) case scenarios (based on real events) and discussion (audiovisual clips); (3) how bullying affects patient safety (presentation); (4) how to support senior staff displaying bullying behaviour (interactive session); (5) how to be assertive without being aggressive (role-play); and (6) practical tips, including the 'Survivors' Guide to Bullying' (interactive session).

EVALUATION

These workshops were designed as practical tools to raise awareness of workplace harassment, and not as a research project to assess the longitudinal impact of the workshops. Feedback from six such workshops as well as informal focus groups from trainees who had previously attended indicated that the subject was useful and necessary.

CONCLUSION

The aim of the workshops was to raise awareness of bullying and undermining in the workplace, and the serious implications they can have for the individual, patients and the NHS as a whole. This will enable a positive culture shift and encourage health care professionals to think before they speak or act.

Comparing relationships between single types of adverse childhood experiences and health-related outcomes: a combined primary data study of eight cross-sectional surveys in England and Wales

OBJECTIVES

Adverse childhood experiences (ACEs) show strong cumulative associations with ill-health across the life course. Harms can arise even in those exposed to a single ACE type but few studies examine such exposure. For individuals experiencing a single ACE type, we examine which ACEs are most strongly related to different health harms.

DESIGN

Secondary analysis of combined data from eight cross-sectional general population ACE surveys.

SETTING

Households in England and Wales.

PARTICIPANTS

20 556 residents aged 18-69 years.

MEASURES

Ten self-reported outcomes were examined: smoking, cannabis use, binge drinking, obesity, sexually transmitted infection, teenage pregnancy, mental well-being, violence perpetration, violence victimisation and incarceration. Adjusted ORs and percentage changes in outcomes were calculated for each type of ACE exposure.

RESULTS

Significance and magnitude of associations between each ACE and outcome varied. Binge drinking was associated with childhood verbal abuse (VA), parental separation (PS) and household alcohol problem (AP), while obesity was linked to sexual abuse (SA) and household mental illness. SA also showed the biggest increase in cannabis use (25.5% vs 10.8%, no ACEs). Household AP was the ACE most strongly associated with violence and incarceration. PS was associated with teenage pregnancy (9.1% vs 3.7%, no ACEs) and 5 other outcomes. VA was associated with 7 of the 10 outcomes examined.

CONCLUSION

Exposure to a single ACE increases risks of poorer outcomes across health-harming behaviours, sexual health, mental well-being and criminal domains. Toxic stress can arise from ACEs such as physical and SA but other more prevalent ACEs (eg, VA, PS) may also contribute substantively to poorer life course health.

Associations between Adverse Childhood Experiences (ACEs) and Lifetime Experience of Car Crashes and Burns: A Cross-Sectional Study

Unintentional injury is a significant cause of disease burden and death. There are known inequalities in the experience of unintentional injuries; however, to date only a limited body of re-search has explored the relationship between exposure to adverse childhood experiences (ACEs) and unintentional injury. Using a cross-sectional sample of the adult general public (n = 4783) in Wales (national) and England (Bolton Local Authority), we identify relationships between ACE exposure and experience of car crashes and burns requiring medical attention across the life course. Individuals who had experienced 4+ ACEs were at significantly increased odds of having ever had each outcome measured. Furthermore, compared to those with no ACEs, those with 4+ were around two times more likely to report having had multiple (i.e., 2+) car crashes and over four times more likely to report having had burns multiple times. Findings expand the evidence base for the association between ACEs and negative health consequences and emphasise the need for effective interventions to prevent ACEs and their impact on life course health and well-being. Such knowledge can also be used to develop a multifaceted approach to injury prevention.

Antimicrobial stewardship using electronic prescribing systems in hospital settings: a scoping review of interventions and outcome measures

Objectives

To identify interventions implemented in hospital electronic prescribing systems and the outcome measures used to monitor their impact.

Methods

We systematically searched CINAHL, EMBASE, Google Scholar and Medline using keywords in three strands: (i) population: hospital inpatient or emergency department; (ii) intervention: electronic prescribing functionality; and (iii) outcome: antimicrobial stewardship. The interventions were grouped into six themes: alerts, order sets, restriction of access, mandated documentation, embedded guidelines and automatic prescription stop. The outcome measures were organized into those that measure the quality or quantity of prescribing or clinical decision support (CDS) activity. The impact of each intervention reported was grouped into a positive, negative or no change.

Results

A total of 28 studies were eligible for inclusion. There were 28 different interventions grouped into the six themes. Alerts visible to the practitioner in the electronic health record (EHR) were most frequently implemented (n = 11/28). Twenty different outcome measures were identified, divided into quality (n = 13/20) and quantity outcomes (n = 4/20) and CDS activity (n = 3/20). One-third of outcomes reported across the 28 studies showed positive change (34.4%, n = 42/122) and 61.4% (n = 75/122) showed no change.

Conclusions

The most frequently implemented interventions were alerts, the majority of which were to influence behaviour or decision-making of the practitioner within the EHR. Quality outcomes were most frequently selected by researchers. The review supports previous research that larger well-designed randomized studies are needed to investigate the impact of interventions on AMS and outcome measures to be standardized.

ACEtimation-The Combined Effect of Adverse Childhood Experiences on Violence, Health-Harming Behaviors, and Mental Ill-Health: Findings across England and Wales

Adverse childhood experiences (ACEs) encompass various adversities, e.g., physical and/or emotional abuse. Understanding the effects of different ACE types on various health outcomes can guide targeted prevention and intervention. We estimated the association between three categories of ACEs in isolation and when they co-occurred. Specifically, the relationship between child maltreatment, witnessing violence, and household dysfunction and the risk of being involved in violence, engaging in health-harming behaviors, and experiencing mental ill-health. Data were from eight cross-sectional surveys conducted in England and Wales between 2012 and 2022. The sample included 21,716 adults aged 18-69 years; 56.6% were female. Exposure to child maltreatment and household dysfunction in isolation were strong predictors of variant outcomes, whereas witnessing violence was not. However, additive models showed that witnessing violence amplified the measured risk beyond expected levels for being a victim or perpetrator of violence. The multiplicative effect of all three ACE categories demonstrated the highest level of risk (RRs from 1.7 to 7.4). Given the increased risk associated with co-occurring ACEs, it is crucial to target individuals exposed to any ACE category to prevent their exposure to additional harm. Implementing universal interventions that safeguard children from physical, emotional, and sexual violence is likely to mitigate a range of subsequent issues, including future involvement in violence.

Adverse childhood and school experiences: a retrospective cross-sectional study examining their associations with health-related behaviours and mental health

BACKGROUND

Adverse childhood experiences (ACEs) increase individuals' risks of poor health across the life course. For children that suffer household-based ACEs, experiences in other settings such as schools have the potential to exacerbate or mitigate risks of poor health. However, few studies have examined such effects. This study aimed to examine relationships between household-based ACEs, school experiences and adult health outcomes.

METHODS

A national cross-sectional household survey (N = 1,868 aged 18+) was undertaken in Wales using random quota sampling (November 2022 to March 2023). Measures included nine household-based ACEs; two measures of childhood school experience (having been bullied, sense of school belonging); and adult health outcomes (smoking, binge drinking, low mental wellbeing, mental illness, violence). Associations between ACEs, school experience and health outcomes were examined using chi squared tests and binary logistic regression.

RESULTS

The proportion reporting both having been bullied and lower school belonging increased with ACE count (0 ACEs 6%, 4 + ACEs 51%). Higher ACE count was independently associated with increased risk of all adult health outcomes except binge drinking, while poorer school experience (having been bullied, lower school belonging) was associated with increased risk of low mental wellbeing, mental illness and violence victimisation. For example, adjusted odds of current mental illness rose to 3.98 in those reporting 4 + ACEs (vs. 0 ACEs) and 3.37 in those reporting both having been bullied and lower school belonging (vs. not bullied, higher school belonging). In individuals with 4 + ACEs, adjusted prevalence of current mental illness reduced from 44% in those reporting both having been bullied and lower school belonging to 19% in those reporting not having been bullied and higher school belonging.

CONCLUSIONS

For children who grow up in adverse home environments, exposure to further adversity at school may amplify risks of poorer health and life outcomes. However, schools are opportune settings for children who lack safety and support at home to recover from stress, develop resilience and access support. Trauma-informed approaches in schools that recognise the impacts of adversity and support children to overcome it have the potential to improve educational and health outcomes. Further research is needed to identify effective approaches.

Examining relationships between adverse childhood experiences and coping during the cost-of-living crisis using a national cross-sectional survey in Wales, UK

OBJECTIVES

Adverse childhood experiences (ACEs) can affect individuals' resilience to stressors and their vulnerability to mental, physical and social harms. This study explored associations between ACEs, financial coping during the cost-of-living crisis and perceived impacts on health and well-being.

DESIGN

National cross-sectional face-to-face survey. Recruitment used a random quota sample of households stratified by health region and deprivation quintile.

SETTING

Households in Wales, UK.

PARTICIPANTS

1880 Welsh residents aged ≥18 years.

MEASURES

Outcome variables were perceived inability to cope financially during the cost-of-living crisis; rising costs of living causing substantial distress and anxiety; and self-reported negative impact of rising costs of living on mental health, physical health, family relationships, local levels of antisocial behaviour and violence, and community support. Nine ACEs were measured retrospectively. Socioeconomic and demographic variables included low household income, economic inactivity, residential deprivation and activity limitation.

RESULTS

The prevalence of all outcomes increased strongly with ACE count. Perceived inability to cope financially during the cost-of-living crisis increased from 14.0% with 0 ACEs to 51.5% with 4+ ACEs. Relationships with ACEs remained after controlling for socioeconomic and demographic factors. Those with 4+ ACEs (vs 0 ACEs) were over three times more likely to perceive they would be unable to cope financially and, correspondingly, almost three times more likely to report substantial distress and anxiety and over three times more likely to report negative impacts on mental health, physical health and family relationships.

CONCLUSIONS

Socioeconomically deprived populations are recognised to be disproportionately impacted by rising costs of living. Our study identifies a history of ACEs as an additional vulnerability that can affect all socioeconomic groups. Definitions of vulnerability during crises and communications with services on who is most likely to be impacted should consider childhood adversity and history of trauma.