tag:theconversation.com,2011:/id/topics/junior-doctors-27510/articlesJunior doctors – The Conversation2023-04-13T14:41:56Ztag:theconversation.com,2011:article/2037012023-04-13T14:41:56Z2023-04-13T14:41:56ZJunior doctors: why pay isn’t the only reason thousands are striking<p>More than 36,000 junior doctors across England are on strike from April 11-15. This is the second junior doctor strike this year. The key reason for these strikes is pay, with calls to increase <a href="https://news.sky.com/story/when-are-junior-doctors-striking-why-this-could-be-the-worst-nhs-strike-yet-12854292">junior doctor salaries</a> by 35%.</p>
<p>But this isn’t the only reason many junior doctors are striking. The strain of working through COVID-19, increasing demands on health services, and growing numbers of medical and nursing colleagues leaving the NHS are all causing stress and burnout for junior doctors. Many hope these strikes may bring about much-needed improvements to their working conditions and ability to provide quality care to their patients.</p>
<h2>Mounting pressure</h2>
<p>There are almost <a href="https://www.gmc-uk.org/-/media/documents/workforce-report-2022---full-report_pdf-94540077.pdf">70,000 junior doctors</a> working in the UK, most of them within the NHS.</p>
<p>While many people may assume a junior doctor is an intern or someone still at medical school, this is actually the label given to any doctor in the UK who has completed their basic medical school education and is continuing medical training. </p>
<p>After medical school, doctors undertake two years of foundation training, then continue training in their chosen speciality under the supervision of a consultant doctor for 3-8 years. This means that, in addition to their 4-7 years of medical school, some junior doctors may be practising for ten years or more.</p>
<p>But not only do junior doctors learn from their supervising consultants, they also conduct much of the day-to-day clinical work of in NHS hospitals and other services. They perform the bulk of diagnoses, clinical procedures, and ongoing management of patients.</p>
<p>They also oversee the medical students and foundation doctors in their teams, and are responsible for running clinical services and departments outside core hours, working overnight and on weekends – with their supervising consultants “on call” for emergencies only. </p>
<p>The pressures on NHS services <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/an-nhs-under-pressure">continue to worsen</a>. Demand for healthcare is rising as the population grows and ages – but staff and bed numbers aren’t keeping pace. Staff shortages in general practice mean an overflow of patients to hospital emergency departments and long waits for admission, as well as <a href="https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/nhs-backlog-data-analysis">lengthy waiting lists</a> for non-emergency treatment. </p>
<p>These pressures make for a heavy, exhausting and constant workload for staff – particularly junior doctors who must juggle patient care with training. </p>
<p>When workload pressures and poor working conditions affect a doctor’s ability to provide good care, they can <a href="https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases">suffer from burnout</a>. Burnout happens <a href="https://www.sciencedirect.com/science/article/abs/pii/S0025619619300680">more often in healthcare professionals</a> compared with the general working population because of the emotionally-taxing, high-energy nature of the job. According to figures from 2022, <a href="https://www.gmc-uk.org/-/media/documents/national-training-survey-summary-report-2022-final_pdf-91826501.pdf">more than 60% of junior doctors</a> in the UK were at risk of suffering burnout. </p>
<p>Burnout is dangerous for both physical and mental wellbeing. <a href="https://www.kingsfund.org.uk/blog/2019/10/nhs-sickness-absence#:%7E:text=Sickness%20absence%20rates%20in%20the,per%20cent%20in%20April%202019.">Sickness absence rates in the NHS</a> are higher than in any other sector of the economy. The most recent NHS staff survey found almost 46% of NHS staff reported feeling unwell in the last 12 months as a <a href="https://www.nhsstaffsurveys.com/static/8c6442c8d92624a830e6656baf633c3f/NHS-Staff-Survey-2022-National-briefing.pdf">result of workplace stress</a>. </p>
<p>Burnout also increases risks of self-harm and suicide. There have been several <a href="https://www.bbc.co.uk/news/uk-england-birmingham-64333162">recent high-profile cases</a> of NHS junior doctor deaths by suicide directly linked to working conditions. Globally, doctors have the <a href="https://bjgp.org/content/68/669/168">highest rate of suicide</a> compared with any other profession. </p>
<h2>Leaving the NHS</h2>
<p>The immense pressure and burnout that junior doctors experience in the NHS has seen a growing number choosing to leave their roles – either to move overseas to practice medicine, or leaving the profession altogether. </p>
<p>In 2011, 71% of junior doctors stayed in training from foundation year to specialisation. Eight years later, this figure was down to <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.419">only 37%</a>. Poor salary, reduced training opportunities, unmanageable work schedules and the impact of being short-staffed are all behind <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hsr2.419">this trend</a>. </p>
<p>Around <a href="https://pearl.plymouth.ac.uk/bitstream/handle/10026.1/18640/Drivers-of-international-migration-research-FINAL-REPORT_pdf-88769526%20with%20Infographic.pdf?sequence=1&isAllowed=y">4,800 doctors</a> leave the UK each year to practice medicine overseas – 70% of whom are under 40. Many move to Australia and New Zealand, which last year launched <a href="https://www.irishtimes.com/health/2022/10/13/australian-government-launches-billboard-campaign-to-recruit-irish-healthcare-staff/">large-scale recruitment campaigns</a> for healthcare workers in the UK and Ireland, promoting better salaries, working conditions, and quality of life for doctors.</p>
<p>By 2031, it’s estimated that half a million extra healthcare staff will be <a href="https://www.health.org.uk/news-and-comment/news/over-a-million-more-health-and-care-staff-needed-in-the-next-decade">needed by the NHS</a> to meet the rising demand for healthcare. But with staff including junior doctors leaving at such alarming rates due to poor working conditions, burnout and low pay, the <a href="https://wchh.onlinelibrary.wiley.com/doi/10.1002/tre.892">NHS will struggle</a> to attract enough recruits from UK and other medical schools to break the <a href="https://www.kingsfund.org.uk/projects/positions/nhs-workforce#:%7E:text=The%20people%20who%20work%20in,demonstrating%20remarkable%20resilience%20and%20commitment">workforce crisis cycle</a>. This in turn will continue to restrict the NHS’s ability to provide safe and efficient healthcare.</p>
<h2>Will striking help?</h2>
<p>In 2010, NHS staff <a href="https://www.nuffieldtrust.org.uk/sites/default/files/2017-01/decade-of-austerity-full-web-final.pdf">budgets were tightened</a> under the UK government’s austerity measures, meaning that pay increments for all staff were capped between 1-2% from 2010-2022. But inflation rates since then have been consistently higher than these pay rises.</p>
<p>So, junior doctors’ salaries haven’t increased as fast as the cost of living. In fact, they’ve experienced a <a href="https://www.bma.org.uk/media/6882/bma-ia-juniors-fact-sheet-for-journalists.pdf">26% real-terms pay cut</a> since 2008. Yet in the same period, the pressures on junior doctors – including from COVID-19, higher numbers of sicker patients, and increased workloads – have only been mounting, influencing their decisions as to whether to <a href="https://www.kingsfund.org.uk/blog/2022/09/workload-issues-affecting-gp-trainees-plans-their-future-careers">stay in the NHS</a>.</p>
<p>Increasing pay may be one solution to improve junior doctor retention. This is likely to increase work satisfaction and morale, which would improve wellbeing and protect against burnout. Higher retention and lower burnout is, in turn, likely to significantly improve working conditions across the NHS – not just for junior doctors but <a href="https://www.kingsfund.org.uk/projects/positions/nhs-workforce">all NHS staff</a>.</p>
<p>But at the same time, attention also needs to be placed on making improvements at an organisational level for junior doctors. Basic things such as rest areas and shower facilities, access to food and drink on shift, safe security and car parking, regular breaks and adequate equipment are all <a href="https://www.nuffieldtrust.org.uk/news-item/fronting-up-to-the-problems-what-can-be-done-to-improve-the-wellbeing-of-nhs-staff">often missing</a> for junior doctors (and all staff) at work. </p>
<p>Alongside pay, these fundamentals should be prioritised – along with introducing much needed <a href="https://theippo.co.uk/rapid-evidence-review-economic-analysis-nhs-staff-wellbeing-and-poor-mental-health/">system-wide approaches</a> to improve the psychological wellbeing of junior doctors and all NHS staff. </p>
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<p><em>An earlier version of this article incorrectly stated that junior doctors in Scotland and Wales were also on strike. This has now been corrected to reflect that only junior doctors in England were striking during this time.</em></p><img src="https://counter.theconversation.com/content/203701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Kirk has been previously by Health Education England (HEE) / NIHR for some of the research underpinning this article. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.</span></em></p><p class="fine-print"><em><span>Jennifer Creese has previously been supported by funding from the Health Research Board of Ireland (HRB-EIA-2017) for some of the research underpinning this article.</span></em></p>Junior doctors face immense pressure at work – and a growing number are choosing to leave the NHS as a result of these poor working conditions.Kate Kirk, Lecturer in Organisational Behaviour in Healthcare, University of LeicesterJennifer Creese, Lecturer in the Department of Population Health Sciences, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1061672018-11-04T19:18:34Z2018-11-04T19:18:34ZBullying and harassment of health workers endangers patient safety<figure><img src="https://images.theconversation.com/files/243616/original/file-20181102-83635-5fkj9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bullying in the medical profession not only affects staff, but also places patients in danger.</span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>Bullying, harassment and other unprofessional behaviours are culturally ingrained in the Australian health-care system.</p>
<p>As we outline today in the <a href="https://www.mja.com.au/">Medical Journal of Australia</a>, between <a href="http://www.iscrr.com.au/__data/assets/pdf_file/0009/297261/Measuring-the-leading-indicators-of-OHS-Survey-Australian-Nursing-Midwifery-federatation-ANMF-Members.pdf">one-quarter</a> and <a href="https://www.surgeons.org/media/22045682/PrevalenceSurvey_Summary-of-Facts_FINAL.pdf">half of doctors</a> and nurses in Australia have been bullied, discriminated against or harassed at work. </p>
<p>This impacts on the way they do their work, and the quality and safety of the care they’re able to provide patients. </p>
<h2>From doctor depression to medical errors</h2>
<p>Workplace bullying in hospitals has been shown to cause <a href="https://www.jpsychores.com/article/S0022-3999%2814%2900372-9/abstract">depression</a>, <a href="https://www.sciencedirect.com/science/article/pii/S0020748913001995?via%3Dihub">anxiety and fatigue</a> among health workers. It <a href="https://www.headsup.org.au/healthy-workplaces/workplace-bullying">can also</a> reduce performance and levels of self-esteem.</p>
<p>These symptoms, along with stress and poor staff satisfaction at work, leads to <a href="http://www.sjweh.fi/show_abstract.php?abstract_id=3579">higher staff absenteeism</a>, impacting continuity of patient care and increasing the workload in already overstretched hospital clinics and wards. </p>
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<p>While we don’t have data from Australia, a <a href="https://www.jointcommissionjournal.com/article/S1553-7250(08)34058-6/fulltext">survey of staff from more than 100 United States’ hospitals</a> give us some clues about the impact. More than two-thirds (71%) of respondents – mainly nurses and doctors – agreed unprofessional behaviour and poor communication contributed to medical errors. </p>
<p>Worryingly, one-quarter of respondents (27%) believed unprofessional behaviour had contributed to a patient’s premature death. </p>
<h2>Communication is compromised</h2>
<p>Good communication among clinical teams <a href="https://qualitysafety.bmj.com/content/13/suppl_1/i85.short">is central</a> to safe care. When team members feel unable to speak up due to negative consequences, care will be compromised.</p>
<p>One <a href="http://pediatrics.aappublications.org/content/136/3/487">study</a> showed medical teams who were treated rudely by an “expert observer” performed significantly worse in a simulated situation where they had to manage a sick infant compared to teams who were treated respectfully. </p>
<p>The teams subjected to rudeness shared less information with each other, and didn’t seek help as often. This led to poorer clinical outcomes for the patients in the simulation.</p>
<p>We can draw parallels with the experience of junior doctors and medical students in Australia, who report being routinely <a href="https://www.mja.com.au/journal/2015/203/4/teaching-humiliation-and-mistreatment-medical-students-clinical-rotations-pilot">“taught by humiliation”</a> and mistreated during clinical training rotations. </p>
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<a href="https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/243633/original/file-20181102-83632-i1e190.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Junior doctors are regularly subjected to rudeness, hostility and aggressive questioning from their teachers.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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<p>Junior clinicians are regularly subjected to rudeness, hostility and aggressive questioning from their teachers. These are the “expert advisors” they’re also supposed to approach for help to manage the patients in their care. </p>
<h2>Poor outcomes for patients</h2>
<p>Serious bullying is just the tip of the iceberg of behaviours that pose a risk to patient safety. Even more subtle unprofessional behaviours – such as passive aggression, public criticism of colleagues, or telling offensive jokes – may interfere with teamwork and the quality of patient care.</p>
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<p>A <a href="https://jamanetwork.com/journals/jamasurgery/fullarticle/2601320">large US study</a> across multiple hospitals found patients’ observations of negative behaviours among surgeons could predict poor patient outcomes.</p>
<p>Hospitals implemented the “patient advocacy reporting system”, where patients were able to report their observations of a clinician’s behaviour while in hospital. This could be dismissing a patient’s questions, rushing them out of consultations, or being rude to other staff members in the patient’s presence.</p>
<p>Among a sample of more than 32,000, those patients who were operated on by surgeons who received a high number of negative patient reports in the past two years had a 14% higher rate of complications than patients whose surgeons acted professionally.</p>
<p>The authors suggest surgeons who are disrespectful to patients probably also behave disrespectfully towards colleagues in the operating theatre. This makes it more difficult to work with others and increases the risk of errors and poor outcomes for the patient.</p>
<h2>Where do we go from here?</h2>
<p>The effects of unprofessional behaviour of health workers are too great to ignore. But pronouncements of a “zero tolerance” for such behaviours are unlikely to bring about change. </p>
<p>Instead, we need evidence-based interventions to reduce the prevalence of negative behaviour, minimise its impact on staff and patients, and normalise a culture of safety and respect. </p>
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Read more:
<a href="https://theconversation.com/we-dont-know-enough-about-mental-health-in-australian-medical-students-70193">We don’t know enough about mental health in Australian medical students</a>
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<p>Culture change is incredibly hard. Unfortunately, there is very limited evidence about the types of interventions which work and bring about change.
We’re <a href="http://aihi.mq.edu.au/project/creating-culture-safety-and-respect">currently evaluating</a> a large-scale system intervention, <a href="http://www.cha.org.au/images/healthmatters/2016/Atkinson_HM80.pdf">called Ethos</a>, at St Vincent’s Hospitals across Australia. </p>
<p>The program aims to enable and empower staff to speak up when they see a problem via a confidential electronic reporting system. Trained colleagues then relay the information back to individual staff involved to encourage self-reflection and correction. Our four-year evaluation will measure how effective this program is at creating real change in behaviours.</p>
<p>We need more system-wide interventions to address the complex problem of bullying and harassment in our health system. But it’s important these interventions are subject to rigorous evaluations which measure both their effects on unprofessional behaviours and clinical outcomes.</p><img src="https://counter.theconversation.com/content/106167/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Johanna Westbrook receives funding from the National Health & Medical Research Council and the Australian Research Council</span></em></p><p class="fine-print"><em><span>Neroli Sunderland receives funding from NHMRC Partnership Project grant . </span></em></p>Research shows unprofessional behaviour and poor communication among doctors and other clinical staff contributes to medical errors. This flows on to worse patient outcomes.Johanna Westbrook, Professor of Health Informatics and Patient Safety, Macquarie UniversityNeroli Sunderland, Research Fellow, Centre for Health Systems and Safety Research, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/898572018-01-15T00:35:38Z2018-01-15T00:35:38ZWhy you should avoid hospitals in January<figure><img src="https://images.theconversation.com/files/201455/original/file-20180110-48498-ig4kb7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Around 3,000 more Australian patients have a complication in their hospital care in January than in other months. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/Xt1qMeOF29E">Rawpixel.com</a></span></figcaption></figure><p>January is the quietest month in Australia. But for hospitals, which provide care 24/7/365, January is a time of big transition. And for patients, that means January is when things are more likely to go wrong.</p>
<p>More than <a href="http://www.medicaldeans.org.au/wp-content/uploads/Table-4.pdf">3,000 newly graduated doctors</a> will enter the next phase of their training in January. New nurses and allied health professionals, such as physiotherapists and hospital pharmacists, also join the workforce in January.</p>
<p>These new staff fill the posts vacated by people one year ahead of them in the pipeline. Last year’s first-year-out doctor goes into his second year of training, and his predecessor goes into her third-year role or leaves the hospital to join a new workplace. </p>
<p>These new minds and hands, and the massive reshuffles of existing staff, disrupt hospitals. Old informal networks break down as new relationships are forged, and the less-experienced staff learn the hospital’s processes and expectations.</p>
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<p>Not surprisingly, this staff disruption has an impact on patient care. Around the world, overblown descriptions of the changeover period as <a href="http://www.bmj.com/content/309/6970/1690.1.full">the “killing season”</a> and of doctors’ first day in the UK as <a href="https://theconversation.com/happy-black-wednesday-every-doctors-nightmare-16106">“Black Wednesday”</a> have become part of medical folklore. </p>
<p>More sober studies of the <a href="http://annals.org/aim/fullarticle/747098/july-effect-impact-academic-year-end-changeover-patient-outcomes-systematic">“July Effect”</a> (so named in the northern hemisphere) have indeed found evidence of worse patient outcomes during the changeover period. </p>
<p>The graph below shows the trend in complications in Australian hospitals over the past few years. It reveals a small but clear “January Effect”. On average, at least one complication occurs in just under 11% of hospital admissions in Australia. But each January, this rate ticks up by more than half a percentage point.</p>
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<a href="https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=476&fit=crop&dpr=1 600w, https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=476&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=476&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=598&fit=crop&dpr=1 754w, https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=598&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/201867/original/file-20180115-101483-12fkrh7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=598&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<h2>What goes wrong?</h2>
<p>New staff might be less adept at monitoring patients, leading to the patient becoming malnourished. Or the new staff may not have acquired sufficient technical skills leading to an accidental puncture or laceration during a procedure. </p>
<p>Other <a href="https://www.safetyandquality.gov.au/our-work/indicators/hospital-acquired-complications/">hospital complications</a> include pressure sores from not moving enough, infections from hygiene breaches, and being given the wrong dose or type of drug. </p>
<p>In January 2015, about 74,000 hospital patients in Australia had a complication of care, about 3,000 more than would have been expected if there were no January Effect. That is 3,000 people suffering complications that might not have arisen had they received care at “normal” times of the year.</p>
<h2>What hospitals can do</h2>
<p>Although the effect is clear, the causes – and therefore, solutions – are not. Is it the effect of the new doctors and other staff who are inadequately prepared for their new responsibilities? Or is it team disruption? Or is it that senior staff take their leave over January, resulting in weaker supervision just when it is needed most? Probably all of the above.</p>
<p>To the extent the problem is diminished supervision, start dates for new staff could be pushed back a month or so. Perhaps senior staff leave could be more evenly spread across the year. </p>
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<p>If the problem is poorly prepared junior staff, then a longer and better induction might be the answer. Typically newly graduated doctors now have a one-week introduction, this could be extended or restructured to include more time to be introduced to the specific practices of units they will be joining.</p>
<p>If the problem is disrupted teamwork, the solution might involve better handover and induction processes, either as part of the formal induction period, or as a structured experience when they join their new unit.</p>
<p>Most likely, all facets will need to be improved. </p>
<h2>What patients and their advocates can do</h2>
<p>The January Effect underlines the fallibility of the people and systems that deliver our hospital care. Australia’s hospital system is staffed by motivated and highly trained people working in well-developed systems, often using state-of-the-art technologies and medicines. </p>
<p>But people can make mistakes, particularly when they are new to a task. Systems can break down. Patients in Australia can take comfort in the safety and quality of hospital care, but they should not assume it is perfect.</p>
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</p>
<hr>
<p>The burden of fixing health system problems should never rest on the shoulders of those with least power – patients and their families and carers. But patients do have a role. Alert and active patients and their families and carers can help identify and prevent errors – and this role becomes slightly more important in January.</p>
<p>Patients often know when they are about to be given the wrong medication, or when their regular medication has been stopped, or when the care they are about to get has not been fully discussed with them so might be wrong. They can speak up and prevent the problem – but too often they feel put down, disempowered and dismissed.</p>
<p>So the simple message for patients is this: if you see something that doesn’t look right, speak up, and speak up again.</p><img src="https://counter.theconversation.com/content/89857/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, and $4 million from BHP Billiton. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and Grattan uses the income to pursue its activities.</span></em></p><p class="fine-print"><em><span>Greg Moran does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New medical staff start in January and may not be as skilled or adept as their predecessors, meaning more things go wrong.Stephen Duckett, Director, Health Program, Grattan InstituteGreg Moran, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/847462017-10-23T14:27:39Z2017-10-23T14:27:39ZNHS staff are burning out – here’s how to make it stop<figure><img src="https://images.theconversation.com/files/191187/original/file-20171020-22957-sgvbcb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">John Gomez/Shutterstock.com</span></span></figcaption></figure><p>Stories about the mounting struggles of NHS staff are becoming routine. Newspapers and newsfeeds tell of how increasing pressures are taking their toll on <a href="https://theconversation.com/nhs-nurses-pressures-taking-toll-on-compassion-and-kindness-our-new-study-shows-84315">nurses</a>, <a href="https://www.theguardian.com/society/2017/oct/08/gps-losing-sleep-over-patient-safety-fears-helen-stokes-lampard">GPs</a>, <a href="https://beta.bps.org.uk/news-and-policy/new-savoy-survey-shows-increasing-mental-health-problems-nhs-psychotherapists">psychological therapists</a> and more. There is a growing <a href="http://www.bbc.co.uk/news/health-41172805">awareness</a> of the emotional impact of working in frontline services and the gender inequalities and biases being <a href="http://www.independent.co.uk/news/uk/politics/junior-doctors-outraged-over-new-contract-that-discriminates-against-single-women-a6963356.html">enshrined in new contracts</a>, most recently for <a href="https://www.theguardian.com/society/2017/jan/02/junior-doctor-nadia-masood-jeremy-hunt-driven-us-out-of-nhs">junior doctors</a>.</p>
<p>Professional bodies have been advocating for change, petitions have been signed. People working in caring professions are often deeply passionate about their work but are not superhuman and cannot be expected to manage the unrealistic pressures many currently face, especially with such limited support. </p>
<p>The central theme to the stories we hear is often burnout: a concept unique in many ways to people working in professions that support others. Burnout <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159015">specifically involves</a> feelings of emotional exhaustion, disconnection and a lowered sense of personal success. </p>
<h2>The wider picture</h2>
<p>The continued austerity agenda has left <a href="https://psychagainstausterity.files.wordpress.com/2015/03/paa-briefing-paper.pdf">many people and families struggling to cope</a>, including many underpaid health and social care practitioners. This is particularly the case for professions that typically receive less financial reimbursement for their work and workforces largely represented by women, such as <a href="http://guiltyfeminist.libsyn.com/59-in-support-of-the-royal-college-of-nursing-foundation-0">nursing</a>.</p>
<p>We know that socioeconomic factors, specifically financial uncertainty, and organisational stressors, such as <a href="http://www.independent.co.uk/news/uk/politics/nhs-privatisation-health-service-exposed-private-cancer-patients-hospitals-treatment-work-government-a7974096.html">rapid privatisation</a> are likely to exacerbate burnout. The <a href="http://www.independent.co.uk/voices/nhs-nurse-bursaries-scrapping-nurse-busaries-will-plunge-the-nhs-into-chaos-and-compromise-care-a7159576.html">withdrawal of certain training bursaries</a> also leaves many underpaid practitioners <a href="https://webcache.googleusercontent.com/search?q=cache:uPDdvds70PgJ:https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/publications/2016/september/005802.pdf+&cd=8&hl=en&ct=clnk&gl=uk">bearing the burden</a> of additional financial debt. All of these factors naturally impact the emotional well-being of those working in care services.</p>
<p>But many healthcare practitioners who experience anxiety worry about the stigma they may face if they speak out – both for experiencing emotional difficulties in the first place and for doing so while being in their caring practitioner role. As my colleague Hannah Wilson, who is a clinical psychologist working for the NHS, demonstrated, stigma around mental health is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5347358/">still prevalent</a> in the workplace. This is a real barrier for healthcare practitioners to seeking help.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=420&fit=crop&dpr=1 600w, https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=420&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=420&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/191189/original/file-20171020-22987-hehk5y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many psychologists feel they should be emotionally ‘sorted’.</span>
<span class="attribution"><span class="source">wavebreakmedia/Shutterstock.com</span></span>
</figcaption>
</figure>
<p>When I spoke with Hannah recently, she explained that “some clinical psychologists worry that experiencing mental health difficulties is seen to have a negative impact on their <a href="https://www.ncbi.nlm.nih.gov/pubmed/25917244">professional competency</a>”. Understandably, <a href="https://blogs.canterbury.ac.uk/discursive/">it seems</a> as though many practitioners struggle to openly discuss their experience of severe emotional distress, despite recognising past personal experiences of distress can enhance empathetic connection when supporting others.</p>
<p>Hannah added that “mental health difficulties are thought to occur on a <a href="http://www.psychminded.co.uk/clinical-psychology-issue-27-july-2003/">continuum</a>, which we all lie on regardless of our qualification or profession”. So of course, health practitioners are just as likely to experience mental health difficulties as anyone else – <a href="https://www.ncbi.nlm.nih.gov/pubmed/28935298">perhaps even more so</a> considering the nature of our work.</p>
<h2>Key issues</h2>
<p>People working in emotionally demanding jobs, in which an “off-day” isn’t usually an option, need to emotionally process negative situations and information. When practitioners are unable to do so, there is a <a href="https://www.ncbi.nlm.nih.gov/pubmed/28928096">direct link</a> to instances of burnout. </p>
<p>Therefore, the absence of psychological support in staff meetings and supervision compound the impact of work-based stress and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28804867">exacerbate the experience of burnout</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28302088">Research</a> suggests that workplace support protects people from emotional burnout. Government strategists need to recognise that it is <a href="http://onlinelibrary.wiley.com/doi/10.1111/jan.13251/abstract;jsessionid=CA4D5A6C78F1A222AACDDE47B174A2D0.f02t04?systemMessage=Wiley+Online+Library+will+be+unavailable+on+Saturday+7th+Oct+from+03.00+EDT+%2F+08%3A00+BST+%2F+12%3A30+IST+%2F+15.00+SGT+to+08.00+EDT+%2F+13.00+BST+%2F+17%3A30+IST+%2F+20.00+SGT+and+Sunday+8th+Oct+from+03.00+EDT+%2F+08%3A00+BST+%2F+12%3A30+IST+%2F+15.00+SGT+to+06.00+EDT+%2F+11.00+BST+%2F+15%3A30+IST+%2F+18.00+SGT+for+essential+maintenance.+Apologies+for+the+inconvenience+caused+">not appropriate</a> to expect NHS staff to simply become even more resilient without organisational support – it is neither moral nor <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0159015">effective</a>.</p>
<p>A change in working culture is essential if the well-being of those working in care services is to be truly addressed. Growing awareness around the importance of emotional well-being in one’s job role has led to a number of new recommendations collated in a <a href="https://beta.bps.org.uk/news-and-policy/improving-workplace-wellbeing-focus-new-bps-report">forthcoming report</a> from the British Psychological Society. The report aims to offer guidance around developing psychologically healthy places of work. </p>
<h2>What can be done?</h2>
<p>In the meantime, what can we do to look after each other and ourselves? I <a href="http://www.jkp.com/uk/sharing-compassion-2.html">recently explored</a> how people in health and social care professions can protect themselves from compassion fatigue and burnout in challenging working environments. The following four steps were found to be key:</p>
<ul>
<li><p>A sense of purpose and of belonging is essential. Developing compassionate relationships with patients and colleagues really helps. But precious time with people is too often compromised due to large caseloads and a target driven culture. This needs to change.</p></li>
<li><p>A safe and supportive space with colleagues or a supervisor for reflectively processing distressing events and information at work is key in protecting practitioners from burnout. Supervision therefore needs to include compassionate connection and a genuine care for a practitioner’s well-being, rather than being only a case management review.</p></li>
<li><p>Feeling valued and wanted is incredibly important for staff, especially during times of difficulty. Sadly, for many NHS workers in front line services, pay and workload demands undermine their sense of being valued and amplify a “never enough” narrative.</p></li>
<li><p>Self-kindness and acceptance are indispensable. Caring professionals are not superhuman and can only work with the means at their disposal.</p></li>
</ul>
<p>Going forwards, everyone has a role to play, whether that is as an ally for someone who needs compassionate support, <a href="https://petition.parliament.uk/petitions?q=nhs&state=all">signing a petition</a> supporting greater fairness and equality or <a href="https://www.theyworkforyou.com/help/">lobbying for greater social justice</a> for staff who offer their care. The current socioeconomic crisis has led to increased demand for health and social care services in the UK, <a href="http://www.pharmatimes.com/news/pressure_rising_on_mental_health_services,_says_nhs_providers_1197738">especially for mental health services</a>. We therefore need to ensure society and government support those who offer care to remain in their professions without compromising their own well-being by promoting social justice and social change.</p><img src="https://counter.theconversation.com/content/84746/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Parry does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People working in caring professions are not superhuman.Sarah Parry, Senior Lecturer and Clinical Psychologist, Manchester Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/821822017-08-10T10:02:18Z2017-08-10T10:02:18ZJunior doctors have a tough job, but preparing them for when things go wrong can help<figure><img src="https://images.theconversation.com/files/181549/original/file-20170809-26064-1u4a1ob.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Challenging times for junior doctors.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Thousands of <a href="https://www.theguardian.com/commentisfree/2017/aug/02/open-letter-junior-doctor-nhs">newly qualified junior doctors</a> headed into UK NHS hospitals in their droves earlier this month, to begin their in-house training. </p>
<p>The first Wednesday in August is the day that marks the start of many doctors’ first steps on the career ladder. This has also been (rather unkindly) dubbed “<a href="http://www.telegraph.co.uk/news/health/news/9441885/Thousands-of-juniors-start-jobs-in-NHS-killing-season.html">killing season</a>” due to the belief that having new junior doctors on the wards will increase medical mistakes and <a href="https://theconversation.com/happy-black-wednesday-every-doctors-nightmare-16106">mortality rates</a>. </p>
<p>This belief has persisted despite the evidence being nebulous at best, with <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0007103">proponents</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/21719058">opponents</a> of “Black Wednesday” (as it’s also called) slugging it out to prove one another wrong.</p>
<p>Of course, starting a new job is never easy, never mind one that puts people’s lives in your hands on a daily basis. For new doctors, the transition into the real world of clinical practice can be extremely rough, leaving many students feeling worthless, stressed, and <a href="http://onlinelibrary.wiley.com/doi/10.1111/medu.12797/full">fearful of engaging with real patients</a>. And if junior doctors aren’t properly supported through this transition they may, understandably, make errors in judgement to the detriment of their patients. </p>
<h2>Team effort</h2>
<p>For most junior doctors, though, after this initial turmoil, they eventually adjust to their new clinical roles. </p>
<p>But even though student doctors are taught how to perform skills manually – such as how to take blood – they aren’t always encouraged to develop the mental skills to help them deal with the uncertainty of becoming a doctor. This means that they are often too scared to ask for help or feedback which impacts negatively upon their performance.</p>
<p><a href="https://www.slideshare.net/slideshow/embed_code/key/zd7eUnHeR4Y3Zk">My research</a> looks at how to help medical students survive and succeed as they go from classroom-based medicine to the messy clinical environment. And to try and make this transition as smooth as possible, my team developed a new solution designed to improve doctor’s confidence, tackle uncertainty, and develop independence. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181550/original/file-20170809-26073-qtea0d.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Fresh blood.</span>
<span class="attribution"><span class="source">Pexels</span></span>
</figcaption>
</figure>
<p>The solution saw teachers training student doctors on dummies with fake blood, but rather than just getting them to do the task, as is normally the case, the students were encouraged to think about a “plan b” – for if the situation went awry.</p>
<p><a href="http://journals.lww.com/academicmedicine/Abstract/2016/11000/Microanalytic_Assessment_of_Self_Regulated.19.aspx">Using a new system</a> we named Feedback+, students were asked how they would find the correct vein, and had to tell the teacher step by step how they would take the blood. The students were then encouraged to work out what they would do if anything went wrong. This meant that students could receive targeted feedback on their responses – honing both their physical and mental skills. This process was repeated using different skills.</p>
<p>This might sound like fairly basic stuff, but the fact of the matter is that for most junior doctors, they are only taught how to do set tasks, rather than how to think around them. On top of this, the current feedback they get is often pretty generic – meaning it isn’t tailored to their individual needs – and it doesn’t give them much say in the matter.</p>
<h2>Putting it to the test</h2>
<p>So to test whether this new system worked or not, we ran our own version of a clinical trial. We gave Feedback+ to one half of a student cohort for three months and tested the differences compared to the other half who got “business as usual” feedback. We measured the students’ independent learning skills and confidence levels multiple times over a year where they made their transition into hospitals. </p>
<p>Our findings show that students in the Feedback+ group reported higher levels of confidence and independent learning. And most of the trainers actually continued to use the new feedback approach even after the study had finished. Most importantly, though, the students who received Feedback+ were more able to plan, monitor, and judge how they were doing. This meant that they could come up with strategies for each day, check their progress, and work out how to perform better the next day.</p>
<p>My research also revealed how the supervisory team (senior doctors in charge) can have a huge impact in easing and supporting young medics into the clinical world. Ultimately, future doctors need to be adaptable in the face of an NHS that is increasingly <a href="https://www.theguardian.com/commentisfree/2017/mar/30/the-guardian-view-on-changes-to-the-nhs-transformative-but-not-sustainable">complex and always evolving</a>, and it is clear how important a fully immersive and team based approach is in the training of new medical staff.</p>
<p>It is of course important that new doctors are able to learn from their mistakes and come back more resilient than ever. But the goal is not to mollycoddle them, rather this approach is about giving them the tools to manage on their own. And given the pressures the UK healthcare system is under right now, we need to prepare our students for instability. Not just for the sake of their own learning experience, but also for the sake of their patients.</p><img src="https://counter.theconversation.com/content/82182/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Billy Bryan receives PhD Scholarship funding from The University of Sheffield Medical School. </span></em></p>Starting a new job is never easy, never mind one that puts people’s lives in your hands on a daily basis.Billy Bryan, PhD researcher in Medical Education, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/635712016-08-08T09:55:49Z2016-08-08T09:55:49ZFive things junior doctors need to know before they hit the wards<figure><img src="https://images.theconversation.com/files/133217/original/image-20160805-466-16mct73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Time to take the rough with the smooth.</span> <span class="attribution"><span class="source">John Gomez/Shutterstock</span></span></figcaption></figure><p>At this time of year around 7,000 newly graduated junior doctors are starting their first full time medical jobs – and thousands of other junior doctors will also be beginning new rotations in new areas of medicine, as their relentless training continues. August is always a milestone for the many thousands of new doctors hitting the wards, but this one is particularly significant because it also marks the date when the new junior doctor’s contract – the subject of such <a href="https://theconversation.com/jeremy-hunt-cant-win-his-fight-with-doctors-they-have-always-held-the-power-in-the-nhs-48421">bitter disputes</a> earlier this year – goes “live”.</p>
<p>The new contract will see premium pay for weekend and unsociable working redefined, and replaced by a broader pay rise for “banded” (standard) hours, which junior doctors perceive will result in a reduction in pay for the many working unsociable shifts. </p>
<p>It is no secret that for many junior doctors, the battles of the last few months have caused <a href="http://www.itv.com/news/update/2016-03-09/junior-doctor-says-nhs-morale-at-an-all-time-low/">staff morale to hit an all time low</a>, “with high levels of anxiety, stress and burnout” reported in many of the junior staff. In response to this, health secretary Jeremy Hunt announced an inquiry looking into why there is such a problem with morale on the wards. But junior doctors <a href="https://www.theguardian.com/society/2016/feb/26/junior-doctors-will-boycott-review-into-poor-morale">have refused to cooperate</a> because the inquiry will not be looking into issues of pay and conditions of service. </p>
<p>If you’re a junior doctor about to head onto the wards you might be wondering what you’re about to get yourself into, and what life on the job will actually be like. Well as part of <a href="http://lubswww.leeds.ac.uk/ceric/publications/policy-contributions/">our research</a> looking at the meaningfulness of work, we have been talking to junior doctors to find out first-hand what morale is actually like for them and their colleagues. So with this in mind, here’s what they’ll need to know before hitting the wards over the next few weeks. </p>
<h2>You will be overworked</h2>
<p>Many junior doctors we spoke to said the volume of work they were expected to do was only just bearable – which is mostly because of understaffing. </p>
<p>One of our interviewees said: “We were constantly understaffed. On one of the jobs I did, there were just three junior doctors, when you knew there should have been five on the rota – so it’s like three people trying to do the job of five people.” </p>
<p>On shifts like this – it’s important to prioritise the most urgent tasks, as well as to delegate. And jobs need to be escalated to senior colleagues if they need to be. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133223/original/image-20160805-470-i05j32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Catch up on those zzz whenever you can.</span>
<span class="attribution"><span class="source">Photographee.eu/Shutterstock</span></span>
</figcaption>
</figure>
<h2>But you will love the job and your colleagues</h2>
<p>Morale was highest among junior doctors who had decided what speciality area of medicine they wanted to pursue because they faced lower levels of insecurity regarding their future career paths. </p>
<p>The doctors we spoke to reported strong feelings of vocational attachment to the day-to-day tasks they carried out, as well as a strong sense of community cohesion being part of a unit with like-minded colleagues. </p>
<p>One of the junior doctors we spoke to simply told us how she is now doing a job she loves – and you can’t say fairer than that.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133230/original/image-20160805-493-10zhmjd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘We’re all in this together’.</span>
<span class="attribution"><span class="source">michaeljung/Shutterstock</span></span>
</figcaption>
</figure>
<h2>At times, you will be frustrated</h2>
<p>Many junior doctors told us about a lack of understanding among non-clinical managers of patient care and medical practice. </p>
<p>One told us about a day spent writing discharge letters: “You’re doing a job you could have done when you were 15-years-old, then you get grief for not doing them fast enough, even though you’re going as fast as possible.” </p>
<p>While days like these are frustrating, it’s important to focus on the fact that each letter gets a patient out of hospital, freeing up space for others.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133225/original/image-20160805-513-14nzp53.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Trying to stay cool, calm and collected is important.</span>
<span class="attribution"><span class="source">michaeljung/Shutterstock</span></span>
</figcaption>
</figure>
<h2>So it’s important not to neglect your social life</h2>
<p>It’s no surprise that a career in medicine involves long and unsociable hours, alongside rigid timetables. One of the registrars we spoke to said: “We have no choice and are given the hours and that is it … it becomes increasingly frustrating that you have no choice.” </p>
<p>But we found that many junior doctors will work together to accommodate and cover each others’ personal and holiday requests. </p>
<p>Also, if a hospital or deanery has a junior doctor’s mess, doctors should take advantage of the socials that are organised – which are usually around payday. They are a great way to blow off steam and catch up with colleagues in a non-clinical setting at the end of a month’s work.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/133231/original/image-20160805-501-1waoxbi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Taking time out from the day job is important.</span>
<span class="attribution"><span class="source">Monkey Business Images/Shutterstock</span></span>
</figcaption>
</figure>
<h2>The reasons behind doing the job</h2>
<p>One junior doctor we spoke to summed up the advice she’d give to newly-starting foundation trainees – which really encapsulates the toughness and optimism of those on the job – despite facing increasing pressure from both patients, managers and the government. </p>
<p>She said: “Keep positive. The work atmosphere and morale in the NHS is not at its best with the current junior doctor contract issues. Life as a junior doctor is hard but we do it for a reason, to care for our patients who need us to do our best and brighten up their day and make them better, so don’t forget why you are doing this job.”</p><img src="https://counter.theconversation.com/content/63571/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andy Charlwood receives funding from The British Academy.</span></em></p><p class="fine-print"><em><span>Hugh Cook and Nick Jephson do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Listen up junior doctors, here is your survival guide.Nick Jephson, Teaching Fellow in Work and Employment Relations, University of LeedsAndy Charlwood, Professor in Human Resources Management and Organisational Behaviour, Loughborough UniversityHugh Cook, Lecturer in Employment Relations, University of LeedsLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/594792016-05-17T10:04:10Z2016-05-17T10:04:10ZAre NHS patients really more likely to die at weekends? Here are the facts<figure><img src="https://images.theconversation.com/files/122698/original/image-20160516-15924-1qzze24.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People admitted to hospital on the weekend tend to be sicker.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=kSbwT8GtuWbq0uWOvABszA-1-1&clicksrc=download_btn_inline&id=406082761&size=medium_jpg&submit_jpg=">spatuletail/shutterstock.com</a></span></figcaption></figure><p>Jeremy Hunt, secretary of state for health, and Philippa Whitford, a Scottish surgeon and MP, had a row about seven-day services during Hunt’s appearance before the Health Select Committee on <a href="http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/spending-review-health-minister-evidence-15-16/">May 9</a>. The issue has also featured in the acrimonious dispute about the junior doctors’ contract <a href="http://www.nhsemployers.org/your-workforce/need-to-know/junior-doctors-contract">negotiations</a> which reopened on the same day. </p>
<p>Hunt and Whitford tussled about the quality and interpretation of evidence about weekend mortality rates and whether we need a seven-day hospital service to set things right. Hunt referred to <a href="https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality">evidence</a> compiled by the Department of Health. It comprises eight studies, of which only four are peer-reviewed articles, the others being reports. Hunt claims that these studies prove that hospital mortality rates are higher for those admitted over the weekend than during the week. Other studies have also found a “weekend effect”. But the effect is smaller when accounting for how sick patients are and it isn’t evident for all conditions. For instance, there is no weekend effect for <a href="http://bit.ly/1TgrYRj">stroke care</a>.</p>
<p>Whitford didn’t dispute the existence of a weekend effect, but said the higher weekend mortality rate is not because more people are dying. Rather the rate is higher because fewer people are admitted at the weekend and they tend to be sicker. This was the conclusion drawn by authors of a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">study</a> published a few days before the committee hearing. Unlike other studies, this made use of both accident and emergency and hospital data. It found a weekend effect only among those admitted to hospital, and it was mainly because they are sicker. The authors conclude that expanding services to seven days a week may cause the mortality rate to fall, but most likely because admissions will increase, not because fewer people will die.</p>
<h2>Hunt’s solution</h2>
<p>Hunt brought out a different message from the same study, saying that more stringent admission criteria shouldn’t be applied at the weekend. He wants four <a href="http://www.parliament.uk/documents/commons-committees/Health/Correspondence/2015-16/Letter-from-the-Secretary-of-State-for-Health-to-the-Chair-on-seven-day-NHS-hospital-services.pdf">priority clinical standards</a> to be met every day for all patients requiring urgent and emergency care. All emergency admissions should have a thorough assessment by a consultant within 14 hours of arrival at hospital; everyone in hospital should have access to consultant-directed diagnostic tests, and to consultant-directed interventions; and high dependency patients must be seen and reviewed by a consultant twice daily, and once a day after transfer to a general ward.</p>
<p>Notably, these standards all relate to the presence of consultants (senior doctors). But, to meet them, a whole range of diagnostic and support services must be made available as well as clinical cover provided by junior doctors. Junior doctors, however, object to plans to consider Saturday a <a href="https://fullfact.org/health/junior-doctors-pay-short-introduction-dispute/">normal working day</a> for calculating their pay.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=458&fit=crop&dpr=1 600w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=458&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=458&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=576&fit=crop&dpr=1 754w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=576&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/122701/original/image-20160516-15899-o6xye5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=576&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Seven-day service is a central feature of the dispute about the junior doctors’ contract.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=7rfstA2OwnA3TqQS_KUN3g-1-27&clicksrc=download_btn_inline&id=412141594&size=medium_jpg&submit_jpg=">Ms Jane Campbell / Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The four standards were chosen as priorities by NHS England and the Academy of Medical Royal colleges set out by NHS England’s <a href="https://www.england.nhs.uk/wp-content/uploads/2013/12/evidence-base.pdf">Seven Days a Week Forum</a>. These are being rolled out across the country, the aim being that they will have been adopted by all hospitals by March 2020.</p>
<p>The standards have already been implemented in some hospitals. The day after the Hunt-Whitford debate, a <a href="http://bit.ly/22dn4tW">study</a> was published in The Lancet comparing hospitals that have implemented the standards with those that have not. This found that patients admitted on Sundays get less than half the attention from consultants than those admitted on Wednesdays. But it also found that variation across hospitals in how much time consultants spend with patients is not associated with the hospital’s mortality rate. So it cannot be said that mortality rates can be reduced simply by increasing consultant cover.</p>
<h2>Where does this leave us?</h2>
<p>Clearly, more evidence is required. First, it remains unclear whether the weekend effect is just a <a href="http://hsr.sagepub.com/content/early/2016/05/05/1355819616649630.full.pdf+html">statistical artefact</a> or whether there is a real problem with a clear cause. </p>
<p>Second, studies should capture a broader array of <a href="http://bit.ly/1YuC6cw">outcomes</a> than just mortality. Even if seven-day services don’t reduce mortality rates, patients may still be better off.</p>
<p>Third, we need to know the costs of the policy. On May 11, the Public Accounts Committee offered <a href="http://bit.ly/1ZEdLBt">harsh criticism</a>, saying: </p>
<blockquote>
<p>no coherent attempt has been made to assess the headcount implications of major policy initiatives such as the seven-day NHS … It beggars belief that such a major policy should be advanced with so flimsy a notion of how it will be funded…</p>
</blockquote>
<p>Finally, implementation of seven-day services was a <a href="https://www.gov.uk/government/news/prime-minister-pledges-to-deliver-7-day-gp-services-by-2020">manifesto commitment</a>. But mortality rates for patients admitted <a href="http://bit.ly/1TgrYRj">overnight</a> are higher than for those admitted during the day; and they are higher for <a href="http://www.nets.nihr.ac.uk/projects/hsdr/11200439">poorer</a> than richer patients. If we want to reduce hospital mortality, perhaps policy could be directed at correcting these differences as well.</p><img src="https://counter.theconversation.com/content/59479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Street receives funding from the National Institute of Health Research and the Department of Health's Policy Research Programme but the views expressed are his own.</span></em></p>While politicians and doctors argue over the data on the weekend effect, it’s important to remember that there are other ways to reduce hospital deaths.Andrew Street, Professor, Centre for Health Economics, University of YorkLicensed as Creative Commons – attribution, no derivatives.